hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|FL,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Madison County Hospital,11/1/2024,2.0.0,Madison County Hospital,"224 NW CRANE AVE MADISON, FL 32340-14003",592319288|FL,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|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_MEDICAL_RENTAL|COMMERCIAL|negotiated_dollar,standard_charge|AETNA_MEDICAL_RENTAL|COMMERCIAL|negotiated_percentage,standard_charge|AETNA_MEDICAL_RENTAL|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA_MEDICAL_RENTAL|COMMERCIAL,standard_charge|AETNA_MEDICAL_RENTAL|COMMERCIAL|methodology,additional_payer_notes|AETNA_MEDICAL_RENTAL|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|CLEAR_ALLIANCE|MEDICAID|negotiated_dollar,standard_charge|CLEAR_ALLIANCE|MEDICAID|negotiated_percentage,standard_charge|CLEAR_ALLIANCE|MEDICAID|negotiated_algorithm,estimated_amount|CLEAR_ALLIANCE|MEDICAID,standard_charge|CLEAR_ALLIANCE|MEDICAID|methodology,additional_payer_notes|CLEAR_ALLIANCE|MEDICAID,standard_charge|HUMANA_EPO|COMMERCIAL|negotiated_dollar,standard_charge|HUMANA_EPO|COMMERCIAL|negotiated_percentage,standard_charge|HUMANA_EPO|COMMERCIAL|negotiated_algorithm,estimated_amount|HUMANA_EPO|COMMERCIAL,standard_charge|HUMANA_EPO|COMMERCIAL|methodology,additional_payer_notes|HUMANA_EPO|COMMERCIAL,standard_charge|HUMANA_HMO|COMMERCIAL|negotiated_dollar,standard_charge|HUMANA_HMO|COMMERCIAL|negotiated_percentage,standard_charge|HUMANA_HMO|COMMERCIAL|negotiated_algorithm,estimated_amount|HUMANA_HMO|COMMERCIAL,standard_charge|HUMANA_HMO|COMMERCIAL|methodology,additional_payer_notes|HUMANA_HMO|COMMERCIAL,standard_charge|HUMANA_MEDICAID_ADVANTAGE_HMO|MEDICAID|negotiated_dollar,standard_charge|HUMANA_MEDICAID_ADVANTAGE_HMO|MEDICAID|negotiated_percentage,standard_charge|HUMANA_MEDICAID_ADVANTAGE_HMO|MEDICAID|negotiated_algorithm,estimated_amount|HUMANA_MEDICAID_ADVANTAGE_HMO|MEDICAID,standard_charge|HUMANA_MEDICAID_ADVANTAGE_HMO|MEDICAID|methodology,additional_payer_notes|HUMANA_MEDICAID_ADVANTAGE_HMO|MEDICAID,standard_charge|HUMANA_MEDICAID_ADVANTAGE_TRADITIONAL|MEDICAID|negotiated_dollar,standard_charge|HUMANA_MEDICAID_ADVANTAGE_TRADITIONAL|MEDICAID|negotiated_percentage,standard_charge|HUMANA_MEDICAID_ADVANTAGE_TRADITIONAL|MEDICAID|negotiated_algorithm,estimated_amount|HUMANA_MEDICAID_ADVANTAGE_TRADITIONAL|MEDICAID,standard_charge|HUMANA_MEDICAID_ADVANTAGE_TRADITIONAL|MEDICAID|methodology,additional_payer_notes|HUMANA_MEDICAID_ADVANTAGE_TRADITIONAL|MEDICAID,standard_charge|HUMANA_POS|COMMERCIAL|negotiated_dollar,standard_charge|HUMANA_POS|COMMERCIAL|negotiated_percentage,standard_charge|HUMANA_POS|COMMERCIAL|negotiated_algorithm,estimated_amount|HUMANA_POS|COMMERCIAL,standard_charge|HUMANA_POS|COMMERCIAL|methodology,additional_payer_notes|HUMANA_POS|COMMERCIAL,standard_charge|HUMANA_PPO|COMMERCIAL|negotiated_dollar,standard_charge|HUMANA_PPO|COMMERCIAL|negotiated_percentage,standard_charge|HUMANA_PPO|COMMERCIAL|negotiated_algorithm,estimated_amount|HUMANA_PPO|COMMERCIAL,standard_charge|HUMANA_PPO|COMMERCIAL|methodology,additional_payer_notes|HUMANA_PPO|COMMERCIAL,standard_charge|LIGHTHOUSE_MEDICAID_ADVANTAGE|MEDICAID|negotiated_dollar,standard_charge|LIGHTHOUSE_MEDICAID_ADVANTAGE|MEDICAID|negotiated_percentage,standard_charge|LIGHTHOUSE_MEDICAID_ADVANTAGE|MEDICAID|negotiated_algorithm,estimated_amount|LIGHTHOUSE_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|LIGHTHOUSE_MEDICAID_ADVANTAGE|MEDICAID|methodology,additional_payer_notes|LIGHTHOUSE_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|MAGELLAN|MEDICAID|negotiated_dollar,standard_charge|MAGELLAN|MEDICAID|negotiated_percentage,standard_charge|MAGELLAN|MEDICAID|negotiated_algorithm,estimated_amount|MAGELLAN|MEDICAID,standard_charge|MAGELLAN|MEDICAID|methodology,additional_payer_notes|MAGELLAN|MEDICAID,standard_charge|MOLINA_FLORIDA_KID_CARE|MEDICAID|negotiated_dollar,standard_charge|MOLINA_FLORIDA_KID_CARE|MEDICAID|negotiated_percentage,standard_charge|MOLINA_FLORIDA_KID_CARE|MEDICAID|negotiated_algorithm,estimated_amount|MOLINA_FLORIDA_KID_CARE|MEDICAID,standard_charge|MOLINA_FLORIDA_KID_CARE|MEDICAID|methodology,additional_payer_notes|MOLINA_FLORIDA_KID_CARE|MEDICAID,standard_charge|MOLINA_MEDICAID_ADVANTAGE|MEDICAID|negotiated_dollar,standard_charge|MOLINA_MEDICAID_ADVANTAGE|MEDICAID|negotiated_percentage,standard_charge|MOLINA_MEDICAID_ADVANTAGE|MEDICAID|negotiated_algorithm,estimated_amount|MOLINA_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|MOLINA_MEDICAID_ADVANTAGE|MEDICAID|methodology,additional_payer_notes|MOLINA_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_dollar,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_percentage,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_algorithm,estimated_amount|MULTIPLAN|COMMERCIAL,standard_charge|MULTIPLAN|COMMERCIAL|methodology,additional_payer_notes|MULTIPLAN|COMMERCIAL,standard_charge|MULTIPLAN_COMPLIMENTARY_NETWORK|COMMERCIAL|negotiated_dollar,standard_charge|MULTIPLAN_COMPLIMENTARY_NETWORK|COMMERCIAL|negotiated_percentage,standard_charge|MULTIPLAN_COMPLIMENTARY_NETWORK|COMMERCIAL|negotiated_algorithm,estimated_amount|MULTIPLAN_COMPLIMENTARY_NETWORK|COMMERCIAL,standard_charge|MULTIPLAN_COMPLIMENTARY_NETWORK|COMMERCIAL|methodology,additional_payer_notes|MULTIPLAN_COMPLIMENTARY_NETWORK|COMMERCIAL,standard_charge|PRESTIGE_HEALTH_CHOICE|MEDICAID|negotiated_dollar,standard_charge|PRESTIGE_HEALTH_CHOICE|MEDICAID|negotiated_percentage,standard_charge|PRESTIGE_HEALTH_CHOICE|MEDICAID|negotiated_algorithm,estimated_amount|PRESTIGE_HEALTH_CHOICE|MEDICAID,standard_charge|PRESTIGE_HEALTH_CHOICE|MEDICAID|methodology,additional_payer_notes|PRESTIGE_HEALTH_CHOICE|MEDICAID,standard_charge|PRIME_HEALTH|MEDICARE|negotiated_dollar,standard_charge|PRIME_HEALTH|MEDICARE|negotiated_percentage,standard_charge|PRIME_HEALTH|MEDICARE|negotiated_algorithm,estimated_amount|PRIME_HEALTH|MEDICARE,standard_charge|PRIME_HEALTH|MEDICARE|methodology,additional_payer_notes|PRIME_HEALTH|MEDICARE,standard_charge|SIMPLY_HEALTH_MEDICAID_ADVANTAGE|MEDICAID|negotiated_dollar,standard_charge|SIMPLY_HEALTH_MEDICAID_ADVANTAGE|MEDICAID|negotiated_percentage,standard_charge|SIMPLY_HEALTH_MEDICAID_ADVANTAGE|MEDICAID|negotiated_algorithm,estimated_amount|SIMPLY_HEALTH_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|SIMPLY_HEALTH_MEDICAID_ADVANTAGE|MEDICAID|methodology,additional_payer_notes|SIMPLY_HEALTH_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|SUNSHINE_HEALTHY_KIDS|MEDICAID|negotiated_dollar,standard_charge|SUNSHINE_HEALTHY_KIDS|MEDICAID|negotiated_percentage,standard_charge|SUNSHINE_HEALTHY_KIDS|MEDICAID|negotiated_algorithm,estimated_amount|SUNSHINE_HEALTHY_KIDS|MEDICAID,standard_charge|SUNSHINE_HEALTHY_KIDS|MEDICAID|methodology,additional_payer_notes|SUNSHINE_HEALTHY_KIDS|MEDICAID,standard_charge|SUNSHINE_MEDICAID_ADVANTAGE|MEDICAID|negotiated_dollar,standard_charge|SUNSHINE_MEDICAID_ADVANTAGE|MEDICAID|negotiated_percentage,standard_charge|SUNSHINE_MEDICAID_ADVANTAGE|MEDICAID|negotiated_algorithm,estimated_amount|SUNSHINE_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|SUNSHINE_MEDICAID_ADVANTAGE|MEDICAID|methodology,additional_payer_notes|SUNSHINE_MEDICAID_ADVANTAGE|MEDICAID,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|UHC_MEDICAID_ADVANTAGE|MEDICAID|negotiated_dollar,standard_charge|UHC_MEDICAID_ADVANTAGE|MEDICAID|negotiated_percentage,standard_charge|UHC_MEDICAID_ADVANTAGE|MEDICAID|negotiated_algorithm,estimated_amount|UHC_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|UHC_MEDICAID_ADVANTAGE|MEDICAID|methodology,additional_payer_notes|UHC_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|WELLCARE|MEDICAID|negotiated_dollar,standard_charge|WELLCARE|MEDICAID|negotiated_percentage,standard_charge|WELLCARE|MEDICAID|negotiated_algorithm,estimated_amount|WELLCARE|MEDICAID,standard_charge|WELLCARE|MEDICAID|methodology,additional_payer_notes|WELLCARE|MEDICAID,standard_charge|YOUTH_SERVICES|MEDICAID|negotiated_dollar,standard_charge|YOUTH_SERVICES|MEDICAID|negotiated_percentage,standard_charge|YOUTH_SERVICES|MEDICAID|negotiated_algorithm,estimated_amount|YOUTH_SERVICES|MEDICAID,standard_charge|YOUTH_SERVICES|MEDICAID|methodology,additional_payer_notes|YOUTH_SERVICES|MEDICAID,standard_charge|min,standard_charge|max,additional_generic_notes
BLOOD ADMIN IP,120000,CDM,391,RC,36430,HCPCS,Outpatient,,,325.48,162.74,,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,221.33,68,,177.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,221.33,
ROOM-BOARD,120003,CDM,110,RC,,,Inpatient,,,595,297.50,,1750,100,,,Per Diem,Pays based on per day rate,1837,100,,,Per Diem,Pays Based on Per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,20,,95.2,Percent of Total Billed Charges,20% of Total Billed Charges,119,20,,95.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,20,,95.2,Percent of Total Billed Charges,20% of Total Billed Charges,119,20,,95.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1547.7,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,1837,
SEMI-PRIVATE ROOM,120005,CDM,120,RC,,,Inpatient,,,595,297.50,,1750,100,,,Per Diem,Pays based on per day rate,1837,100,,,Per Diem,Pays Based on Per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,20,,95.2,Percent of Total Billed Charges,20% of Total Billed Charges,119,20,,95.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,20,,95.2,Percent of Total Billed Charges,20% of Total Billed Charges,119,20,,95.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1547.7,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,1837,
SWINGBED R & B,120007,CDM,110,RC,,,Inpatient,,,520,260.00,,1750,100,,,Per Diem,Pays based on per day rate,1837,100,,,Per Diem,Pays Based on Per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1547.7,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,1837,
SEMI-PVT SWINGBED,120009,CDM,120,RC,,,Inpatient,,,520,260.00,,1750,100,,,Per Diem,Pays based on per day rate,1837,100,,,Per Diem,Pays Based on Per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1547.7,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,1837,
ISOLATION,120013,CDM,160,RC,,,Inpatient,,,811.13,405.57,,1750,100,,,Per Diem,Pays based on per day rate,1837,100,,,Per Diem,Pays Based on Per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.23,20,,129.784,Percent of Total Billed Charges,20% of Total Billed Charges,162.23,20,,129.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.23,20,,129.784,Percent of Total Billed Charges,20% of Total Billed Charges,162.23,20,,129.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1547.7,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.23,1837,
THORACENTESIS,120015,CDM,360,RC,32554,HCPCS,Outpatient,,,450.11,225.06,,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,306.07,68,,244.856,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,312,
PARACENTESIS,120017,CDM,360,RC,49082,HCPCS,Outpatient,,,450.11,225.06,,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,306.07,68,,244.856,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665,
LUMBAR PUNCTURE,120019,CDM,360,RC,62270,HCPCS,Outpatient,,,288.4,144.20,,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,196.11,68,,156.888,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,312,
TRANSPORTATION NON-EMERGENCY,120020,CDM,540,RC,A0426,HCPCS,Outpatient,,,927,463.50,,602.55,65,,482.04,Percent of Total Billed Charges,65% of Total Billed Charges,630.36,68,,504.288,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.4,20,,148.32,Percent of Total Billed Charges,20% of Total Billed Charges,185.4,20,,148.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.4,20,,148.32,Percent of Total Billed Charges,20% of Total Billed Charges,185.4,20,,148.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,602.55,65,,482.04,Percent of Total Billed Charges,65% of Total Billed Charges,602.55,65,,482.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,444,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.4,630.36,
DEBRIDEMENT ALL KIND,120021,CDM,360,RC,16020,HCPCS,Outpatient,,,288.4,144.20,,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,196.11,68,,156.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,196.11,
I&D,120023,CDM,360,RC,96523,HCPCS,Outpatient,,,288.4,144.20,,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,196.11,68,,156.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.2,50,,115.36,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,196.11,
CUT DOWN,120025,CDM,360,RC,,,Outpatient,,,288.4,144.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.94,35,,80.752,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,187.46,
URETHRAL DILITATIONS,120027,CDM,360,RC,,,Outpatient,,,288.4,144.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.94,35,,80.752,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,187.46,
BLOOD PROC/STORAGE,120029,CDM,390,RC,P9016,HCPCS,Outpatient,,,560.85,280.43,,364.55,65,,291.64,Percent of Total Billed Charges,65% of Total Billed Charges,381.38,68,,305.104,Percent of Total Billed Charges,68% of Total Billed Charges,104,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,112.17,20,,89.736,Percent of Total Billed Charges,20% of Total Billed Charges,112.17,20,,89.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.17,20,,89.736,Percent of Total Billed Charges,20% of Total Billed Charges,112.17,20,,89.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.55,65,,291.64,Percent of Total Billed Charges,65% of Total Billed Charges,364.55,65,,291.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,381.38,
CENTRAL LINE INFUSIO,120031,CDM,360,RC,,,Outpatient,,,288.4,144.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.94,35,,80.752,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,187.46,
PLACEMENT/PICC LINE,120033,CDM,360,RC,36569,HCPCS,Outpatient,,,288.4,144.20,,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,196.11,68,,156.888,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,57.68,20,,46.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,187.46,65,,149.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,312,
EXTERNAL PACER,120035,CDM,271,RC,92953,HCPCS,Outpatient,,,155.53,77.77,,101.09,65,,80.872,Percent of Total Billed Charges,65% of Total Billed Charges,105.76,68,,84.608,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.11,20,,24.888,Percent of Total Billed Charges,20% of Total Billed Charges,31.11,20,,24.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.11,20,,24.888,Percent of Total Billed Charges,20% of Total Billed Charges,31.11,20,,24.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.09,65,,80.872,Percent of Total Billed Charges,65% of Total Billed Charges,101.09,65,,80.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.11,296,
LIFE PK8 W/ELECTRODE,120037,CDM,730,RC,93041,HCPCS,Outpatient,,,161.71,80.86,,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,109.96,68,,87.968,Percent of Total Billed Charges,68% of Total Billed Charges,11.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.79,148,
GASTROSTOMY TUBE REP,120038,CDM,750,RC,43762,HCPCS,Outpatient,,,207.03,103.52,,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,140.78,68,,112.624,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,312,
ACCU-CHECK,120935,CDM,301,RC,82962,HCPCS,Outpatient,,,6.49,3.25,,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,4.41,68,,3.528,Percent of Total Billed Charges,68% of Total Billed Charges,4.49,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,50,,2.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,4.49,
PEG/G-TUBE- CHANGE,121038,CDM,750,RC,43762,HCPCS,Outpatient,,,207.03,103.52,,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,140.78,68,,112.624,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,312,
BLOOD ADMINISTRATION- OBS,140000,CDM,391,RC,36430,HCPCS,Outpatient,,,325.48,162.74,,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,221.33,68,,177.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,221.33,
OBSERVATION 1ST HOUR,140001,CDM,762,RC,G0378,HCPCS,Outpatient,,,206,103.00,,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,140.08,68,,112.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,980,
OBSERV/EA ADDL HOUR,140003,CDM,762,RC,G0378,HCPCS,Outpatient,,,15.71,7.86,,10.21,65,,8.168,Percent of Total Billed Charges,65% of Total Billed Charges,10.68,68,,8.544,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,20,,2.512,Percent of Total Billed Charges,20% of Total Billed Charges,3.14,20,,2.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,20,,2.512,Percent of Total Billed Charges,20% of Total Billed Charges,3.14,20,,2.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.21,65,,8.168,Percent of Total Billed Charges,65% of Total Billed Charges,10.21,65,,8.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,980,
OU ER CHF CP ASTHM,140005,CDM,762,RC,99219,HCPCS,Outpatient,,,206,103.00,,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,140.08,68,,112.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,980,
OU DIR CHF CP ASTHMA,140007,CDM,762,RC,99220,HCPCS,Outpatient,,,206,103.00,,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,140.08,68,,112.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,980,
OU NUR ASSESS DIRECT,140009,CDM,762,RC,,,Outpatient,,,81.11,40.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.72,65,,42.176,Percent of Total Billed Charges,65% of Total Billed Charges,52.72,65,,42.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,980,
OBSERV/EA ADDITIONAL HR,140011,CDM,762,RC,G0378,HCPCS,Outpatient,,,15.71,7.86,,10.21,65,,8.168,Percent of Total Billed Charges,65% of Total Billed Charges,10.68,68,,8.544,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,20,,2.512,Percent of Total Billed Charges,20% of Total Billed Charges,3.14,20,,2.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,20,,2.512,Percent of Total Billed Charges,20% of Total Billed Charges,3.14,20,,2.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.21,65,,8.168,Percent of Total Billed Charges,65% of Total Billed Charges,10.21,65,,8.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,980,
DIRECT REFER HOSP OBSERV,140012,CDM,762,RC,G0379,HCPCS,Outpatient,,,448.05,224.03,,291.23,65,,232.984,Percent of Total Billed Charges,65% of Total Billed Charges,304.67,68,,243.736,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.61,20,,71.688,Percent of Total Billed Charges,20% of Total Billed Charges,89.61,20,,71.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.61,20,,71.688,Percent of Total Billed Charges,20% of Total Billed Charges,89.61,20,,71.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.23,65,,232.984,Percent of Total Billed Charges,65% of Total Billed Charges,291.23,65,,232.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,980,
IV INF/HYDRATE 1ST HR - OBS,140013,CDM,260,RC,96360,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
IV/INF HYDRAT ADD HR - OBS,140014,CDM,260,RC,96361,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,53.67,
IV INF/MED 1ST HR - OBS,140015,CDM,260,RC,96365,HCPCS,Outpatient,,,161.71,80.86,,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,109.96,68,,87.968,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,109.96,
IV/INF MED ADD HR - OBS,140016,CDM,260,RC,96366,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
IV/INF/SEQ MED 1ST HR - OBS,140017,CDM,260,RC,96367,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
IV INF/CONCURRENT-OBSERV,140018,CDM,260,RC,96368,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
INJ SC/IM - OBS,140019,CDM,260,RC,96372,HCPCS,Outpatient,,,49.44,24.72,,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,33.62,68,,26.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,53.67,
INJ IV PUSH- OBS,140020,CDM,260,RC,96374,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
INJ/IV PUSH NEW/SQ MED OBS,140021,CDM,260,RC,96375,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
INJ/IV PUSH SAME MED OBS,140022,CDM,260,RC,96376,HCPCS,Outpatient,,,67.98,33.99,,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,46.23,68,,36.984,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
STRAIGHT CATH PRN IF UNABLE TO VOID,140023,CDM,761,RC,51701,HCPCS,Outpatient,,,122.06,61.03,,79.34,65,,63.472,Percent of Total Billed Charges,65% of Total Billed Charges,83,68,,66.4,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.41,20,,19.528,Percent of Total Billed Charges,20% of Total Billed Charges,24.41,20,,19.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.41,20,,19.528,Percent of Total Billed Charges,20% of Total Billed Charges,24.41,20,,19.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.34,65,,63.472,Percent of Total Billed Charges,65% of Total Billed Charges,79.34,65,,63.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.41,178,
CATH INSERT FOLEY,140024,CDM,761,RC,51702,HCPCS,Outpatient,,,122.06,61.03,,79.34,65,,63.472,Percent of Total Billed Charges,65% of Total Billed Charges,83,68,,66.4,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.41,20,,19.528,Percent of Total Billed Charges,20% of Total Billed Charges,24.41,20,,19.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.41,20,,19.528,Percent of Total Billed Charges,20% of Total Billed Charges,24.41,20,,19.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.34,65,,63.472,Percent of Total Billed Charges,65% of Total Billed Charges,79.34,65,,63.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.41,178,
CATH INSERT COMPLICATED - OBS,140025,CDM,761,RC,51703,HCPCS,Outpatient,,,146.47,73.24,,95.21,65,,76.168,Percent of Total Billed Charges,65% of Total Billed Charges,99.6,68,,79.68,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.29,20,,23.432,Percent of Total Billed Charges,20% of Total Billed Charges,29.29,20,,23.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.29,20,,23.432,Percent of Total Billed Charges,20% of Total Billed Charges,29.29,20,,23.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.21,65,,76.168,Percent of Total Billed Charges,65% of Total Billed Charges,95.21,65,,76.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.29,178,
INFLUENZA ADMIN-OBS,140026,CDM,771,RC,90674,HCPCS,Outpatient,,,36.05,18.03,,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,24.51,68,,19.608,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,85,
PNEUMOCL ADMIN - OBS,140027,CDM,771,RC,90732,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,85,
ADM SARSCOV2 PFIZER 1ST DOSE,140028,CDM,771,RC,0001A,HCPCS,Outpatient,,,56.65,28.33,,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,38.52,68,,30.816,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,85,
ADMIN SARSCOV2 PFIZER 2ND DOSE,140029,CDM,771,RC,0002A,HCPCS,Outpatient,,,94.76,47.38,,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,64.44,68,,51.552,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,85,
ADMIN SARSCOV2 MODERNA 1ST DOSE,140030,CDM,771,RC,0011A,HCPCS,Outpatient,,,56.65,28.33,,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,38.52,68,,30.816,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,85,
ADMIN SARSCOV2 MODERNA 2ND DOSE,140031,CDM,771,RC,0012A,HCPCS,Outpatient,,,94.76,47.38,,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,64.44,68,,51.552,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,85,
REGENERON INFUSION,140032,CDM,771,RC,M0244,HCPCS,Outpatient,,,463.5,231.75,,301.28,65,,241.024,Percent of Total Billed Charges,65% of Total Billed Charges,315.18,68,,252.144,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.7,20,,74.16,Percent of Total Billed Charges,20% of Total Billed Charges,92.7,20,,74.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.7,20,,74.16,Percent of Total Billed Charges,20% of Total Billed Charges,92.7,20,,74.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.28,65,,241.024,Percent of Total Billed Charges,65% of Total Billed Charges,301.28,65,,241.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,315.18,
ADM MODERNA BOOSTER,140033,CDM,771,RC,0013A,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,85,
ADM PFIZER BOOSTER,140034,CDM,771,RC,0003A,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,85,
IV/INF HYDRATION 1ST HR -OUTPATIENT,141221,CDM,260,RC,96360,HCPCS,Outpatient,,,84,42.00,,54.6,65,,43.68,Percent of Total Billed Charges,65% of Total Billed Charges,57.12,68,,45.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,20,,13.44,Percent of Total Billed Charges,20% of Total Billed Charges,16.8,20,,13.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,20,,13.44,Percent of Total Billed Charges,20% of Total Billed Charges,16.8,20,,13.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.6,65,,43.68,Percent of Total Billed Charges,65% of Total Billed Charges,54.6,65,,43.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,57.12,
CBC W AUTO DIFFE EXTERNAL,400042,CDM,305,RC,85025,HCPCS,Outpatient,,,550,275.00,,357.5,65,,286,Percent of Total Billed Charges,65% of Total Billed Charges,374,68,,299.2,Percent of Total Billed Charges,68% of Total Billed Charges,11.04,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,357.5,65,,286,Percent of Total Billed Charges,65% of Total Billed Charges,357.5,65,,286,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.04,374,
INTERACTIVE COMPLEXITY,820001,CDM,972,RC,90785,HCPCS,Outpatient,,,34.74,17.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,14.33,110,,,Fee Schedule,110% of Multiplan Fee Schedule,14.33,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,16.48,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,56.82,100,,,Case Rate,Pays Based on per visit rate,4.22,100,,,Fee Schedule,100% of FL Medicaid Rate,4.22,100,,,Fee Schedule,100% of FL Medicaid rate,4.22,56.82,
PSYCHOTHERAPY (30 MIN),820003,CDM,972,RC,90832,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
PSYCHOLOGICAL TRAUMA,820006,CDM,972,RC,90839,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
FAMILY PSYCHOTHERAPY (WITHOUT PATIENT),820007,CDM,972,RC,90846,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
FAMILY PSYCHOTHERAPY (WITH PATIENT),820008,CDM,972,RC,90847,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
PROLONGED VISIT (90 MIN OR MORE),820009,CDM,972,RC,99354,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
ADD-ON PROLONGED VISIT (ADD 30MIN),820010,CDM,972,RC,99355,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
..ZZ TEST VITAMIN D 25-OH TOTAL IA,919191,CDM,301,RC,82306,HCPCS,Outpatient,,,100.94,50.47,,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,68.64,68,,54.912,Percent of Total Billed Charges,68% of Total Billed Charges,42.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.47,50,,40.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,68.64,
..ZZ TEST CULTURE URINE ROUTINE,919192,CDM,301,RC,82306,HCPCS,Outpatient,,,100.94,50.47,,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,68.64,68,,54.912,Percent of Total Billed Charges,68% of Total Billed Charges,42.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.47,50,,40.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,68.64,
..ZZ TEST ANA W/ REFLEX,919193,CDM,301,RC,82306,HCPCS,Outpatient,,,100.94,50.47,,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,68.64,68,,54.912,Percent of Total Billed Charges,68% of Total Billed Charges,42.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.47,50,,40.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,68.64,
..ZZ TEST CBC,919194,CDM,301,RC,82306,HCPCS,Outpatient,,,100.94,50.47,,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,68.64,68,,54.912,Percent of Total Billed Charges,68% of Total Billed Charges,42.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.47,50,,40.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,68.64,
MISC SUPPLY NURSING,999001,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY EMERGENCY DEPARTMENT,999010,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY OPERATING ROOM,999022,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY MATERIALS MANAGEMENT,999025,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY ANESTHESIA,999028,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY PHARMACY,999030,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY LABRATORY,999040,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY RADIOLOGY,999050,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY PHYSICAL THERAPY,999061,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY OCCUPATIONAL THERAPY,999062,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY SPEECH THERAPY,999063,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY RESPIRATORY THERAPY,999064,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY CARDIAC REHAB,999065,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY DIETARY,999070,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY CLINIC,999080,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY SPECIALTY OFFICES,999081,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY NURSING ADMINISTRATION,999100,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY CASE MGMT/ UTIL REV,999104,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY MAINTENANCE,999106,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY ENVIRONMENTAL SVCS,999107,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY ADMISSIONS,999200,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY HEALTH INFO MANAGEMENT,999201,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY BUSINESS OFFICE,999202,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY LAUNDRY,999460,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY INFORMATION TECHNOLOGY,999900,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY ADMINISTRATION,999901,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY FINANCE,999902,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY HUMAN RESOURCES,999903,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY MARKETING,999905,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MISC SUPPLY ACCOUNTS PAYABLE,999907,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INSERTION OF MIDLINE CATHETER,1000029,CDM,272,RC,36410,HCPCS,Outpatient,,,89.61,44.81,,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,60.93,68,,48.744,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,60.93,
INTERACTIVE COMPLEXITY,1010001,CDM,972,RC,90785,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
PSYCHOTHERAPY (30 MIN),1010003,CDM,972,RC,90832,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
PSYCHOTHERAPY (45 MIN),1010004,CDM,972,RC,90834,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
PSYCHOTHERAPY (53 MIN OR MORE),1010005,CDM,914,RC,90837,HCPCS,Outpatient,,,340,170.00,,221,65,,176.8,Percent of Total Billed Charges,65% of Total Billed Charges,231.2,68,,184.96,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68,20,,54.4,Percent of Total Billed Charges,20% of Total Billed Charges,68,20,,54.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68,20,,54.4,Percent of Total Billed Charges,20% of Total Billed Charges,68,20,,54.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221,65,,176.8,Percent of Total Billed Charges,65% of Total Billed Charges,221,65,,176.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170,50,,136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68,231.2,
PSYCHOLOGICAL TRAUMA,1010006,CDM,972,RC,90839,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
FAMILY PSYCHOTHERAPY (WITHOUT PATIENT),1010007,CDM,972,RC,90846,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
FAMILY PSYCHOTHERAPY (WITH PATIENT),1010008,CDM,972,RC,90847,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
DIAGNOSTIC INTERVIEW (1HR 45MIN),1010009,CDM,972,RC,99354,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
DIAGNOSTIC INTERVIEW (ADDITIONAL 30MIN),1010010,CDM,972,RC,99355,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
RP SIMPLE 2.6-7.5CM GEN/TRUNK/EXTRM,1030000,CDM,450,RC,12002,HCPCS,Outpatient,,,159.65,79.83,,103.77,65,,83.016,Percent of Total Billed Charges,65% of Total Billed Charges,108.56,68,,86.848,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.93,20,,25.544,Percent of Total Billed Charges,20% of Total Billed Charges,31.93,20,,25.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.93,20,,25.544,Percent of Total Billed Charges,20% of Total Billed Charges,31.93,20,,25.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.77,65,,83.016,Percent of Total Billed Charges,65% of Total Billed Charges,103.77,65,,83.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.93,178,
ER BURN DRES/DEBRID SM,1030901,CDM,450,RC,16020,HCPCS,Outpatient,,,143.17,71.59,,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,97.36,68,,77.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,178,
ER BURN DRES/DEBRID MED,1030905,CDM,450,RC,16025,HCPCS,Outpatient,,,210.12,105.06,,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,142.88,68,,114.304,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,419,
ER BURN DRES/DEBRID LG,1030909,CDM,450,RC,16030,HCPCS,Outpatient,,,234.84,117.42,,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,159.69,68,,127.752,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,312,
ER BURN/DEBRID LG,1030911,CDM,450,RC,16030,HCPCS,Outpatient,,,234.84,117.42,,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,159.69,68,,127.752,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,312,
ER DRAIN/FINGER ABCESS,1030913,CDM,450,RC,26010,HCPCS,Outpatient,,,213.21,106.61,,138.59,65,,110.872,Percent of Total Billed Charges,65% of Total Billed Charges,144.98,68,,115.984,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.64,20,,34.112,Percent of Total Billed Charges,20% of Total Billed Charges,42.64,20,,34.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.64,20,,34.112,Percent of Total Billed Charges,20% of Total Billed Charges,42.64,20,,34.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.59,65,,110.872,Percent of Total Billed Charges,65% of Total Billed Charges,138.59,65,,110.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.64,178,
ER BLOOD TRANSFUSION,1030927,CDM,391,RC,36430,HCPCS,Outpatient,,,325.48,162.74,,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,221.33,68,,177.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,221.33,
BLOOD TRANSFUSION-FLOOR,1030928,CDM,391,RC,36430,HCPCS,Outpatient,,,325.48,162.74,,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,221.33,68,,177.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,221.33,
ER IV REMOVE CENT LINE,1030929,CDM,450,RC,36589,HCPCS,Outpatient,,,450.11,225.06,,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,306.07,68,,244.856,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,312,
ER GASTROSTOMY TUBE CHG,1030931,CDM,450,RC,43762,HCPCS,Outpatient,,,207.03,103.52,,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,140.78,68,,112.624,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,312,
ER ACCU-CHECK,1030935,CDM,301,RC,82962,HCPCS,Outpatient,,,6.49,3.25,,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,4.41,68,,3.528,Percent of Total Billed Charges,68% of Total Billed Charges,4.49,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,50,,2.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,4.49,
ER ADMIN IMMUNE INITIAL,1030937,CDM,771,RC,90471,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,85,
ER INJ IMMUNIZATION EACH ADDITIONAL,1030938,CDM,771,RC,90472,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,85,
INJ ADD IMMUNIZATION,1030939,CDM,771,RC,90472,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,85,
ER GAS INTUB LAVAG,1030941,CDM,450,RC,43753,HCPCS,Outpatient,,,204.97,102.49,,133.23,65,,106.584,Percent of Total Billed Charges,65% of Total Billed Charges,139.38,68,,111.504,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.99,20,,32.792,Percent of Total Billed Charges,20% of Total Billed Charges,40.99,20,,32.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.99,20,,32.792,Percent of Total Billed Charges,20% of Total Billed Charges,40.99,20,,32.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.23,65,,106.584,Percent of Total Billed Charges,65% of Total Billed Charges,133.23,65,,106.584,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.99,178,
ER IV INF/HYDRAT 1ST HR,1030943,CDM,260,RC,96360,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
ER IV INF/HYDRAT ADD HR,1030945,CDM,260,RC,96361,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,53.67,
ER INF/HYDRATION 1ST HR,1030946,CDM,260,RC,96360,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
ER IV INF/MED 1ST HR,1030947,CDM,260,RC,96365,HCPCS,Outpatient,,,161.71,80.86,,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,109.96,68,,87.968,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,109.96,
ER IV INF/MED ADD HR,1030949,CDM,260,RC,96366,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
ER IV INF/SEQ MED 1STHR,1030951,CDM,260,RC,96367,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
ER IV INF/CONCURRENT,1030953,CDM,260,RC,96368,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
ER INJECTION SC/IM,1030955,CDM,450,RC,96372,HCPCS,Outpatient,,,49.44,24.72,,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,33.62,68,,26.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,50,,19.776,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,53.67,
ER INJECTION SC/IM OP,1030957,CDM,450,RC,96372,HCPCS,Outpatient,,,49.44,24.72,,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,33.62,68,,26.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,50,,19.776,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,53.67,
ER INJECTION IV PUSH,1030959,CDM,450,RC,96374,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.26,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
IV INF/MED 1ST HR - OP,1030960,CDM,260,RC,96365,HCPCS,Outpatient,,,161.71,80.86,,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,109.96,68,,87.968,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,109.96,
INJECTION IV PUSH OP,1030961,CDM,450,RC,96374,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.26,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
INJ/ IVP NEW SEQ MED OP,1030962,CDM,260,RC,96375,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
ER INJ/IV PUSH NEW/SEQ MED,1030963,CDM,450,RC,96375,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
ER INF/SEQMED 1ST HOUR,1030964,CDM,260,RC,96367,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
ER INJ/IV PUSH SAME MED,1030965,CDM,450,RC,96376,HCPCS,Outpatient,,,67.98,33.99,,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,46.23,68,,36.984,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,50,,27.192,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
ER INF/HYDRATION ADD HR - OP,1030966,CDM,260,RC,96366,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
ER INJ/IV PUSH SAME MED OP,1030967,CDM,761,RC,96376,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
DRESSING CHANGE MINOR - ER,1030968,CDM,761,RC,99211,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,53.67,
ER LEVEL 1,1030969,CDM,450,RC,99281,HCPCS,Outpatient,,,98.88,49.44,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,735,
ER LEVEL 1 WI PROCD,1030971,CDM,450,RC,99281,HCPCS,Outpatient,,,98.88,49.44,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,735,
ER LEVEL 2,1030973,CDM,450,RC,99282,HCPCS,Outpatient,,,126.69,63.35,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.34,20,,20.272,Percent of Total Billed Charges,20% of Total Billed Charges,25.34,20,,20.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.34,20,,20.272,Percent of Total Billed Charges,20% of Total Billed Charges,25.34,20,,20.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.35,65,,65.88,Percent of Total Billed Charges,65% of Total Billed Charges,82.35,65,,65.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.34,735,
ER LEVEL 2 WI PROCD,1030975,CDM,450,RC,99282,HCPCS,Outpatient,,,126.69,63.35,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.34,20,,20.272,Percent of Total Billed Charges,20% of Total Billed Charges,25.34,20,,20.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.34,20,,20.272,Percent of Total Billed Charges,20% of Total Billed Charges,25.34,20,,20.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.35,65,,65.88,Percent of Total Billed Charges,65% of Total Billed Charges,82.35,65,,65.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.34,735,
ER LEVEL 3,1030977,CDM,450,RC,99283,HCPCS,Outpatient,,,190.55,95.28,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,735,
ER LEVEL 3 WI PROCD,1030979,CDM,450,RC,99283,HCPCS,Outpatient,,,190.55,95.28,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,735,
ER LEVEL 4,1030981,CDM,450,RC,99284,HCPCS,Outpatient,,,304.88,152.44,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.98,20,,48.784,Percent of Total Billed Charges,20% of Total Billed Charges,60.98,20,,48.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.98,20,,48.784,Percent of Total Billed Charges,20% of Total Billed Charges,60.98,20,,48.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.17,65,,158.536,Percent of Total Billed Charges,65% of Total Billed Charges,198.17,65,,158.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,735,
ER LEVEL 4 WI PROCD,1030983,CDM,450,RC,99284,HCPCS,Outpatient,,,304.88,152.44,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.98,20,,48.784,Percent of Total Billed Charges,20% of Total Billed Charges,60.98,20,,48.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.98,20,,48.784,Percent of Total Billed Charges,20% of Total Billed Charges,60.98,20,,48.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.17,65,,158.536,Percent of Total Billed Charges,65% of Total Billed Charges,198.17,65,,158.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,735,
ER LEVEL 5,1030985,CDM,450,RC,99285,HCPCS,Outpatient,,,453.2,226.60,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.64,20,,72.512,Percent of Total Billed Charges,20% of Total Billed Charges,90.64,20,,72.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.64,20,,72.512,Percent of Total Billed Charges,20% of Total Billed Charges,90.64,20,,72.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.58,65,,235.664,Percent of Total Billed Charges,65% of Total Billed Charges,294.58,65,,235.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,735,
ER LEVEL 5 WI PROCD,1030987,CDM,450,RC,99285,HCPCS,Outpatient,,,453.2,226.60,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.64,20,,72.512,Percent of Total Billed Charges,20% of Total Billed Charges,90.64,20,,72.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.64,20,,72.512,Percent of Total Billed Charges,20% of Total Billed Charges,90.64,20,,72.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.58,65,,235.664,Percent of Total Billed Charges,65% of Total Billed Charges,294.58,65,,235.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,735,
ER CRIT CARE 30-74 MIN,1030989,CDM,450,RC,99291,HCPCS,Outpatient,,,621.09,310.55,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.22,20,,99.376,Percent of Total Billed Charges,20% of Total Billed Charges,124.22,20,,99.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.22,20,,99.376,Percent of Total Billed Charges,20% of Total Billed Charges,124.22,20,,99.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,403.71,65,,322.968,Percent of Total Billed Charges,65% of Total Billed Charges,403.71,65,,322.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,735,
ER CRI CARE 30-74M W/PR,1030991,CDM,450,RC,99291,HCPCS,Outpatient,,,621.09,310.55,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.22,20,,99.376,Percent of Total Billed Charges,20% of Total Billed Charges,124.22,20,,99.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.22,20,,99.376,Percent of Total Billed Charges,20% of Total Billed Charges,124.22,20,,99.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,403.71,65,,322.968,Percent of Total Billed Charges,65% of Total Billed Charges,403.71,65,,322.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,735,
ER CRIT CARE EA ADD 30M,1030993,CDM,450,RC,99292,HCPCS,Outpatient,,,164.8,82.40,,700,100,,,Case Rate,Pays based on Per visit rate,735,100,,,Case rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,510,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,735,
ER FB AUDITORY CANL,1030995,CDM,450,RC,69200,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,178,
ADMIN FLU VACCINE,1030997,CDM,771,RC,90674,HCPCS,Outpatient,,,20.6,10.30,,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,14.01,68,,11.208,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,85,
ADMIN PNEUMONIA VAC,1030999,CDM,771,RC,G0009,HCPCS,Outpatient,,,20.6,10.30,,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,14.01,68,,11.208,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,85,
ER RP SIMPLE TO 2.5CM,1031001,CDM,450,RC,12001,HCPCS,Outpatient,,,220.94,110.47,,143.61,65,,114.888,Percent of Total Billed Charges,65% of Total Billed Charges,150.24,68,,120.192,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,20,,35.352,Percent of Total Billed Charges,20% of Total Billed Charges,44.19,20,,35.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,20,,35.352,Percent of Total Billed Charges,20% of Total Billed Charges,44.19,20,,35.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.61,65,,114.888,Percent of Total Billed Charges,65% of Total Billed Charges,143.61,65,,114.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,178,
ER RP SIMPLE 2.6-7.5CM,1031003,CDM,450,RC,12002,HCPCS,Outpatient,,,233.4,116.70,,151.71,65,,121.368,Percent of Total Billed Charges,65% of Total Billed Charges,158.71,68,,126.968,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.68,20,,37.344,Percent of Total Billed Charges,20% of Total Billed Charges,46.68,20,,37.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.68,20,,37.344,Percent of Total Billed Charges,20% of Total Billed Charges,46.68,20,,37.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.71,65,,121.368,Percent of Total Billed Charges,65% of Total Billed Charges,151.71,65,,121.368,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.68,178,
ER RP SIMPLE 7.6-12.5CM,1031005,CDM,450,RC,12004,HCPCS,Outpatient,,,297.98,148.99,,193.69,65,,154.952,Percent of Total Billed Charges,65% of Total Billed Charges,202.63,68,,162.104,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.6,20,,47.68,Percent of Total Billed Charges,20% of Total Billed Charges,59.6,20,,47.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.6,20,,47.68,Percent of Total Billed Charges,20% of Total Billed Charges,59.6,20,,47.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.69,65,,154.952,Percent of Total Billed Charges,65% of Total Billed Charges,193.69,65,,154.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,202.63,
RP SIMPLE 2.5 OR < FACE,1031007,CDM,450,RC,12011,HCPCS,Outpatient,,,299.11,149.56,,194.42,65,,155.536,Percent of Total Billed Charges,65% of Total Billed Charges,203.39,68,,162.712,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.82,20,,47.856,Percent of Total Billed Charges,20% of Total Billed Charges,59.82,20,,47.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.82,20,,47.856,Percent of Total Billed Charges,20% of Total Billed Charges,59.82,20,,47.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.42,65,,155.536,Percent of Total Billed Charges,65% of Total Billed Charges,194.42,65,,155.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,203.39,
ER RP SIMP 5.1-7.5 HEAD/FACE,1031009,CDM,450,RC,12014,HCPCS,Outpatient,,,344.54,172.27,,223.95,65,,179.16,Percent of Total Billed Charges,65% of Total Billed Charges,234.29,68,,187.432,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.91,20,,55.128,Percent of Total Billed Charges,20% of Total Billed Charges,68.91,20,,55.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.91,20,,55.128,Percent of Total Billed Charges,20% of Total Billed Charges,68.91,20,,55.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.95,65,,179.16,Percent of Total Billed Charges,65% of Total Billed Charges,223.95,65,,179.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,234.29,
ER RP SIMP 7.6-12.5 HEAD/FACE,1031011,CDM,450,RC,12015,HCPCS,Outpatient,,,425.39,212.70,,276.5,65,,221.2,Percent of Total Billed Charges,65% of Total Billed Charges,289.27,68,,231.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.08,20,,68.064,Percent of Total Billed Charges,20% of Total Billed Charges,85.08,20,,68.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.08,20,,68.064,Percent of Total Billed Charges,20% of Total Billed Charges,85.08,20,,68.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,276.5,65,,221.2,Percent of Total Billed Charges,65% of Total Billed Charges,276.5,65,,221.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,289.27,
ER RP INTER 2.5CM NECK,1031013,CDM,450,RC,12041,HCPCS,Outpatient,,,278.72,139.36,,181.17,65,,144.936,Percent of Total Billed Charges,65% of Total Billed Charges,189.53,68,,151.624,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.74,20,,44.592,Percent of Total Billed Charges,20% of Total Billed Charges,55.74,20,,44.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.74,20,,44.592,Percent of Total Billed Charges,20% of Total Billed Charges,55.74,20,,44.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.17,65,,144.936,Percent of Total Billed Charges,65% of Total Billed Charges,181.17,65,,144.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,189.53,
ER RP INTER 2.6-7.5 NEK,1031015,CDM,450,RC,12042,HCPCS,Outpatient,,,362.56,181.28,,235.66,65,,188.528,Percent of Total Billed Charges,65% of Total Billed Charges,246.54,68,,197.232,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.51,20,,58.008,Percent of Total Billed Charges,20% of Total Billed Charges,72.51,20,,58.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.51,20,,58.008,Percent of Total Billed Charges,20% of Total Billed Charges,72.51,20,,58.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.66,65,,188.528,Percent of Total Billed Charges,65% of Total Billed Charges,235.66,65,,188.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,246.54,
ER RP INTER 7.6-12.5 NK,1031017,CDM,450,RC,12044,HCPCS,Outpatient,,,458.35,229.18,,297.93,65,,238.344,Percent of Total Billed Charges,65% of Total Billed Charges,311.68,68,,249.344,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,91.67,20,,73.336,Percent of Total Billed Charges,20% of Total Billed Charges,91.67,20,,73.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.67,20,,73.336,Percent of Total Billed Charges,20% of Total Billed Charges,91.67,20,,73.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.93,65,,238.344,Percent of Total Billed Charges,65% of Total Billed Charges,297.93,65,,238.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,419,
ER RP INT TO 2.5 SCALP,1031019,CDM,450,RC,12031,HCPCS,Outpatient,,,236.9,118.45,,153.99,65,,123.192,Percent of Total Billed Charges,65% of Total Billed Charges,161.09,68,,128.872,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.38,20,,37.904,Percent of Total Billed Charges,20% of Total Billed Charges,47.38,20,,37.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.38,20,,37.904,Percent of Total Billed Charges,20% of Total Billed Charges,47.38,20,,37.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.99,65,,123.192,Percent of Total Billed Charges,65% of Total Billed Charges,153.99,65,,123.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.38,178,
ER RP INT 2.6-7.5 SCALP,1031021,CDM,450,RC,12032,HCPCS,Outpatient,,,335.78,167.89,,218.26,65,,174.608,Percent of Total Billed Charges,65% of Total Billed Charges,228.33,68,,182.664,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.16,20,,53.728,Percent of Total Billed Charges,20% of Total Billed Charges,67.16,20,,53.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.16,20,,53.728,Percent of Total Billed Charges,20% of Total Billed Charges,67.16,20,,53.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.26,65,,174.608,Percent of Total Billed Charges,65% of Total Billed Charges,218.26,65,,174.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,228.33,
ER RP INT 7.6-12.5 SCLP,1031023,CDM,450,RC,12034,HCPCS,Outpatient,,,407.88,203.94,,265.12,65,,212.096,Percent of Total Billed Charges,65% of Total Billed Charges,277.36,68,,221.888,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,81.58,20,,65.264,Percent of Total Billed Charges,20% of Total Billed Charges,81.58,20,,65.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.58,20,,65.264,Percent of Total Billed Charges,20% of Total Billed Charges,81.58,20,,65.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.12,65,,212.096,Percent of Total Billed Charges,65% of Total Billed Charges,265.12,65,,212.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,419,
ER RP INTER 2.5 FACE,1031025,CDM,450,RC,12051,HCPCS,Outpatient,,,299.73,149.87,,194.82,65,,155.856,Percent of Total Billed Charges,65% of Total Billed Charges,203.82,68,,163.056,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.82,65,,155.856,Percent of Total Billed Charges,65% of Total Billed Charges,194.82,65,,155.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,203.82,
ER RP INT 2.6-5.0 FACE,1031027,CDM,450,RC,12052,HCPCS,Outpatient,,,413.03,206.52,,268.47,65,,214.776,Percent of Total Billed Charges,65% of Total Billed Charges,280.86,68,,224.688,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.61,20,,66.088,Percent of Total Billed Charges,20% of Total Billed Charges,82.61,20,,66.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.61,20,,66.088,Percent of Total Billed Charges,20% of Total Billed Charges,82.61,20,,66.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.47,65,,214.776,Percent of Total Billed Charges,65% of Total Billed Charges,268.47,65,,214.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,280.86,
ER RP INT 5.1-7.5 FACE,1031029,CDM,450,RC,12053,HCPCS,Outpatient,,,502.64,251.32,,326.72,65,,261.376,Percent of Total Billed Charges,65% of Total Billed Charges,341.8,68,,273.44,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,20,,80.424,Percent of Total Billed Charges,20% of Total Billed Charges,100.53,20,,80.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,20,,80.424,Percent of Total Billed Charges,20% of Total Billed Charges,100.53,20,,80.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.72,65,,261.376,Percent of Total Billed Charges,65% of Total Billed Charges,326.72,65,,261.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,341.8,
ER RP COMP 2.6-7.5 FACE,1031031,CDM,450,RC,12032,HCPCS,Outpatient,,,1031.03,515.52,,670.17,65,,536.136,Percent of Total Billed Charges,65% of Total Billed Charges,701.1,68,,560.88,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.21,20,,164.968,Percent of Total Billed Charges,20% of Total Billed Charges,206.21,20,,164.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.21,20,,164.968,Percent of Total Billed Charges,20% of Total Billed Charges,206.21,20,,164.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,670.17,65,,536.136,Percent of Total Billed Charges,65% of Total Billed Charges,670.17,65,,536.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,701.1,
ER RP COMP 2.6-7.5 TRK,1031033,CDM,450,RC,12032,HCPCS,Outpatient,,,518.09,259.05,,336.76,65,,269.408,Percent of Total Billed Charges,65% of Total Billed Charges,352.3,68,,281.84,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.62,20,,82.896,Percent of Total Billed Charges,20% of Total Billed Charges,103.62,20,,82.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.62,20,,82.896,Percent of Total Billed Charges,20% of Total Billed Charges,103.62,20,,82.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.76,65,,269.408,Percent of Total Billed Charges,65% of Total Billed Charges,336.76,65,,269.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,352.3,
ER BURN_WOUND DRESSING,1031035,CDM,450,RC,16000,HCPCS,Outpatient,,,106.27,53.14,,69.08,65,,55.264,Percent of Total Billed Charges,65% of Total Billed Charges,72.26,68,,57.808,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.25,20,,17,Percent of Total Billed Charges,20% of Total Billed Charges,21.25,20,,17,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.25,20,,17,Percent of Total Billed Charges,20% of Total Billed Charges,21.25,20,,17,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.08,65,,55.264,Percent of Total Billed Charges,65% of Total Billed Charges,69.08,65,,55.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.25,178,
ER BURN SMALL W/O ANES,1031037,CDM,450,RC,16020,HCPCS,Outpatient,,,143.17,71.59,,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,97.36,68,,77.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,178,
ER BURN MEDIUM W/O ANES,1031039,CDM,450,RC,,,Outpatient,,,190.55,95.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.69,35,,53.352,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,123.86,
ER BURN LARGE W/O ANES,1031041,CDM,450,RC,,,Outpatient,,,234.84,117.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.19,35,,65.752,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,152.65,
ER DISLOC SHDLR W/MA,1031043,CDM,450,RC,23650,HCPCS,Outpatient,,,540.75,270.38,,351.49,65,,281.192,Percent of Total Billed Charges,65% of Total Billed Charges,367.71,68,,294.168,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,108.15,20,,86.52,Percent of Total Billed Charges,20% of Total Billed Charges,108.15,20,,86.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.15,20,,86.52,Percent of Total Billed Charges,20% of Total Billed Charges,108.15,20,,86.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.49,65,,281.192,Percent of Total Billed Charges,65% of Total Billed Charges,351.49,65,,281.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,367.71,
ER DISLOC ELBOW WO ANES,1031045,CDM,450,RC,24600,HCPCS,Outpatient,,,561.35,280.68,,364.88,65,,291.904,Percent of Total Billed Charges,65% of Total Billed Charges,381.72,68,,305.376,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,112.27,20,,89.816,Percent of Total Billed Charges,20% of Total Billed Charges,112.27,20,,89.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.27,20,,89.816,Percent of Total Billed Charges,20% of Total Billed Charges,112.27,20,,89.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.88,65,,291.904,Percent of Total Billed Charges,65% of Total Billed Charges,364.88,65,,291.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,381.72,
CAST LONG ARM,1031047,CDM,450,RC,,,Outpatient,,,195.7,97.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.5,35,,54.8,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,127.21,
CAST SHORT ARM,1031049,CDM,450,RC,,,Outpatient,,,157.59,78.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.52,20,,25.216,Percent of Total Billed Charges,20% of Total Billed Charges,31.52,20,,25.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.52,20,,25.216,Percent of Total Billed Charges,20% of Total Billed Charges,31.52,20,,25.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.43,65,,81.944,Percent of Total Billed Charges,65% of Total Billed Charges,102.43,65,,81.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.16,35,,44.128,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.52,102.43,
ER DISLOCATION KNEE W/MA,1031050,CDM,450,RC,27550,HCPCS,Outpatient,,,540.75,270.38,,351.49,65,,281.192,Percent of Total Billed Charges,65% of Total Billed Charges,367.71,68,,294.168,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,108.15,20,,86.52,Percent of Total Billed Charges,20% of Total Billed Charges,108.15,20,,86.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.15,20,,86.52,Percent of Total Billed Charges,20% of Total Billed Charges,108.15,20,,86.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.49,65,,281.192,Percent of Total Billed Charges,65% of Total Billed Charges,351.49,65,,281.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,367.71,
CAST SHORT LEG,1031053,CDM,450,RC,,,Outpatient,,,196.73,98.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.35,20,,31.48,Percent of Total Billed Charges,20% of Total Billed Charges,39.35,20,,31.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.35,20,,31.48,Percent of Total Billed Charges,20% of Total Billed Charges,39.35,20,,31.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.87,65,,102.296,Percent of Total Billed Charges,65% of Total Billed Charges,127.87,65,,102.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.86,35,,55.088,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.35,127.87,
CASTWALKIN SHORT LEG,1031057,CDM,450,RC,,,Outpatient,,,223.51,111.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.7,20,,35.76,Percent of Total Billed Charges,20% of Total Billed Charges,44.7,20,,35.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.7,20,,35.76,Percent of Total Billed Charges,20% of Total Billed Charges,44.7,20,,35.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.28,65,,116.224,Percent of Total Billed Charges,65% of Total Billed Charges,145.28,65,,116.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.23,35,,62.584,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.7,145.28,
ER APPL SPLINT LONG ARM,1031059,CDM,450,RC,29105,HCPCS,Outpatient,,,153.47,76.74,,99.76,65,,79.808,Percent of Total Billed Charges,65% of Total Billed Charges,104.36,68,,83.488,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.69,20,,24.552,Percent of Total Billed Charges,20% of Total Billed Charges,30.69,20,,24.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.69,20,,24.552,Percent of Total Billed Charges,20% of Total Billed Charges,30.69,20,,24.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.76,65,,79.808,Percent of Total Billed Charges,65% of Total Billed Charges,99.76,65,,79.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.69,178,
ER APP SPLINT SHORT ARM,1031061,CDM,450,RC,29125,HCPCS,Outpatient,,,140.08,70.04,,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,95.25,68,,76.2,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.02,178,
ER APP SPLINT FINGER,1031063,CDM,450,RC,29131,HCPCS,Outpatient,,,140.08,70.04,,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,95.25,68,,76.2,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.02,178,
ER APPL SPLINT LONG LEG,1031065,CDM,450,RC,29505,HCPCS,Outpatient,,,145.23,72.62,,94.4,65,,75.52,Percent of Total Billed Charges,65% of Total Billed Charges,98.76,68,,79.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.05,20,,23.24,Percent of Total Billed Charges,20% of Total Billed Charges,29.05,20,,23.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.05,20,,23.24,Percent of Total Billed Charges,20% of Total Billed Charges,29.05,20,,23.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.4,65,,75.52,Percent of Total Billed Charges,65% of Total Billed Charges,94.4,65,,75.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.05,178,
ER APP SPLINT SHORT LEG,1031067,CDM,450,RC,29515,HCPCS,Outpatient,,,133.9,66.95,,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,68,,72.84,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,178,
ER WR SIMPLE 20.1-30CM,1031069,CDM,450,RC,,,Outpatient,,,670.53,335.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.11,20,,107.288,Percent of Total Billed Charges,20% of Total Billed Charges,134.11,20,,107.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.11,20,,107.288,Percent of Total Billed Charges,20% of Total Billed Charges,134.11,20,,107.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,435.84,65,,348.672,Percent of Total Billed Charges,65% of Total Billed Charges,435.84,65,,348.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.69,35,,187.752,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,435.84,
ART/ASP/INJ SM JOINT,1031071,CDM,450,RC,20600,HCPCS,Outpatient,,,208.06,104.03,,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,141.48,68,,113.184,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,178,
ART/ASP/IN INT JOINT,1031073,CDM,450,RC,20605,HCPCS,Outpatient,,,208.06,104.03,,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,141.48,68,,113.184,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,178,
ER I&D ABCESS SIMPLE,1031075,CDM,450,RC,10060,HCPCS,Outpatient,,,143.17,71.59,,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,97.36,68,,77.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,178,
ER I&D ABCESS COMPL,1031077,CDM,450,RC,10061,HCPCS,Outpatient,,,276.04,138.02,,179.43,65,,143.544,Percent of Total Billed Charges,65% of Total Billed Charges,187.71,68,,150.168,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.21,20,,44.168,Percent of Total Billed Charges,20% of Total Billed Charges,55.21,20,,44.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.21,20,,44.168,Percent of Total Billed Charges,20% of Total Billed Charges,55.21,20,,44.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.43,65,,143.544,Percent of Total Billed Charges,65% of Total Billed Charges,179.43,65,,143.544,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,187.71,
ER EXCISION OF NAIL,1031079,CDM,450,RC,11750,HCPCS,Outpatient,,,435.69,217.85,,283.2,65,,226.56,Percent of Total Billed Charges,65% of Total Billed Charges,296.27,68,,237.016,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.14,20,,69.712,Percent of Total Billed Charges,20% of Total Billed Charges,87.14,20,,69.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.14,20,,69.712,Percent of Total Billed Charges,20% of Total Billed Charges,87.14,20,,69.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.2,65,,226.56,Percent of Total Billed Charges,65% of Total Billed Charges,283.2,65,,226.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,296.27,
ER I&D ASPIR OF ABCESS,1031081,CDM,450,RC,10060,HCPCS,Outpatient,,,134.93,67.47,,87.7,65,,70.16,Percent of Total Billed Charges,65% of Total Billed Charges,91.75,68,,73.4,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.7,65,,70.16,Percent of Total Billed Charges,65% of Total Billed Charges,87.7,65,,70.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.99,178,
ER I&D EXT THROM HEMO,1031083,CDM,450,RC,10140,HCPCS,Outpatient,,,234.84,117.42,,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,159.69,68,,127.752,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,46.97,20,,37.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,152.65,65,,122.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,665,
ER I&D/EXC SKIN LESION,1031085,CDM,450,RC,10060,HCPCS,Outpatient,,,269.86,134.93,,175.41,65,,140.328,Percent of Total Billed Charges,65% of Total Billed Charges,183.5,68,,146.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.97,20,,43.176,Percent of Total Billed Charges,20% of Total Billed Charges,53.97,20,,43.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.97,20,,43.176,Percent of Total Billed Charges,20% of Total Billed Charges,53.97,20,,43.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.41,65,,140.328,Percent of Total Billed Charges,65% of Total Billed Charges,175.41,65,,140.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,183.5,
ER FB SUBCUTANEOUS SIMP,1031087,CDM,450,RC,10120,HCPCS,Outpatient,,,210.12,105.06,,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,142.88,68,,114.304,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,178,
ER FB SUBCUTANEOUS COMP,1031089,CDM,450,RC,10121,HCPCS,Outpatient,,,1318.4,659.20,,856.96,65,,685.568,Percent of Total Billed Charges,65% of Total Billed Charges,896.51,68,,717.208,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,263.68,20,,210.944,Percent of Total Billed Charges,20% of Total Billed Charges,263.68,20,,210.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.68,20,,210.944,Percent of Total Billed Charges,20% of Total Billed Charges,263.68,20,,210.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,856.96,65,,685.568,Percent of Total Billed Charges,65% of Total Billed Charges,856.96,65,,685.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,896.51,
ER FB MUSCLE SIMPLE,1031091,CDM,450,RC,20520,HCPCS,Outpatient,,,877.56,438.78,,570.41,65,,456.328,Percent of Total Billed Charges,65% of Total Billed Charges,596.74,68,,477.392,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.51,20,,140.408,Percent of Total Billed Charges,20% of Total Billed Charges,175.51,20,,140.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.51,20,,140.408,Percent of Total Billed Charges,20% of Total Billed Charges,175.51,20,,140.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,570.41,65,,456.328,Percent of Total Billed Charges,65% of Total Billed Charges,570.41,65,,456.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,596.74,
ER FB REMOVAL-VAGINA,1031092,CDM,450,RC,57415,HCPCS,Outpatient,,,1734.52,867.26,,1127.44,65,,901.952,Percent of Total Billed Charges,65% of Total Billed Charges,1179.47,68,,943.576,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,346.9,20,,277.52,Percent of Total Billed Charges,20% of Total Billed Charges,346.9,20,,277.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.9,20,,277.52,Percent of Total Billed Charges,20% of Total Billed Charges,346.9,20,,277.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1127.44,65,,901.952,Percent of Total Billed Charges,65% of Total Billed Charges,1127.44,65,,901.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1478,
ER FB MUSCLE DEEP COMP,1031093,CDM,450,RC,20525,HCPCS,Outpatient,,,1318.4,659.20,,856.96,65,,685.568,Percent of Total Billed Charges,65% of Total Billed Charges,896.51,68,,717.208,Percent of Total Billed Charges,68% of Total Billed Charges,479,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,263.68,20,,210.944,Percent of Total Billed Charges,20% of Total Billed Charges,263.68,20,,210.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.68,20,,210.944,Percent of Total Billed Charges,20% of Total Billed Charges,263.68,20,,210.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,856.96,65,,685.568,Percent of Total Billed Charges,65% of Total Billed Charges,856.96,65,,685.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1478,
ER FB INTRANASAL,1031095,CDM,450,RC,30300,HCPCS,Outpatient,,,145.23,72.62,,94.4,65,,75.52,Percent of Total Billed Charges,65% of Total Billed Charges,98.76,68,,79.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.05,20,,23.24,Percent of Total Billed Charges,20% of Total Billed Charges,29.05,20,,23.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.05,20,,23.24,Percent of Total Billed Charges,20% of Total Billed Charges,29.05,20,,23.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.4,65,,75.52,Percent of Total Billed Charges,65% of Total Billed Charges,94.4,65,,75.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.05,178,
ER FB PHARYNX,1031097,CDM,450,RC,42809,HCPCS,Outpatient,,,272.95,136.48,,177.42,65,,141.936,Percent of Total Billed Charges,65% of Total Billed Charges,185.61,68,,148.488,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.59,20,,43.672,Percent of Total Billed Charges,20% of Total Billed Charges,54.59,20,,43.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.59,20,,43.672,Percent of Total Billed Charges,20% of Total Billed Charges,54.59,20,,43.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.42,65,,141.936,Percent of Total Billed Charges,65% of Total Billed Charges,177.42,65,,141.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,185.61,
ER FB EYE CONJ SUPERF,1031099,CDM,450,RC,65205,HCPCS,Outpatient,,,227.63,113.82,,147.96,65,,118.368,Percent of Total Billed Charges,65% of Total Billed Charges,154.79,68,,123.832,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,20,,36.424,Percent of Total Billed Charges,20% of Total Billed Charges,45.53,20,,36.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,20,,36.424,Percent of Total Billed Charges,20% of Total Billed Charges,45.53,20,,36.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.96,65,,118.368,Percent of Total Billed Charges,65% of Total Billed Charges,147.96,65,,118.368,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,178,
ER FB EYE CONJ EMBD,1031101,CDM,450,RC,65210,HCPCS,Outpatient,,,237.93,118.97,,154.65,65,,123.72,Percent of Total Billed Charges,65% of Total Billed Charges,161.79,68,,129.432,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.59,20,,38.072,Percent of Total Billed Charges,20% of Total Billed Charges,47.59,20,,38.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.59,20,,38.072,Percent of Total Billed Charges,20% of Total Billed Charges,47.59,20,,38.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.65,65,,123.72,Percent of Total Billed Charges,65% of Total Billed Charges,154.65,65,,123.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.59,178,
ER FB CORNEAL W/O LAMP,1031103,CDM,450,RC,65220,HCPCS,Outpatient,,,227.63,113.82,,147.96,65,,118.368,Percent of Total Billed Charges,65% of Total Billed Charges,154.79,68,,123.832,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,20,,36.424,Percent of Total Billed Charges,20% of Total Billed Charges,45.53,20,,36.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,20,,36.424,Percent of Total Billed Charges,20% of Total Billed Charges,45.53,20,,36.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.96,65,,118.368,Percent of Total Billed Charges,65% of Total Billed Charges,147.96,65,,118.368,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,178,
ER FB CORNEAL W/LAMP,1031105,CDM,450,RC,65222,HCPCS,Outpatient,,,237.93,118.97,,154.65,65,,123.72,Percent of Total Billed Charges,65% of Total Billed Charges,161.79,68,,129.432,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.59,20,,38.072,Percent of Total Billed Charges,20% of Total Billed Charges,47.59,20,,38.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.59,20,,38.072,Percent of Total Billed Charges,20% of Total Billed Charges,47.59,20,,38.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.65,65,,123.72,Percent of Total Billed Charges,65% of Total Billed Charges,154.65,65,,123.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.59,178,
ER FB IMPACTED CERUMEN,1031107,CDM,450,RC,69210,HCPCS,Outpatient,,,96.82,48.41,,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,65.84,68,,52.672,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,178,
ER NASAL HEM/SIMPLE ANT,1031109,CDM,450,RC,30901,HCPCS,Outpatient,,,202.91,101.46,,131.89,65,,105.512,Percent of Total Billed Charges,65% of Total Billed Charges,137.98,68,,110.384,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.58,20,,32.464,Percent of Total Billed Charges,20% of Total Billed Charges,40.58,20,,32.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.58,20,,32.464,Percent of Total Billed Charges,20% of Total Billed Charges,40.58,20,,32.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.89,65,,105.512,Percent of Total Billed Charges,65% of Total Billed Charges,131.89,65,,105.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.58,178,
ER NASAL HEM ANT/COMPLX,1031111,CDM,450,RC,30903,HCPCS,Outpatient,,,283.25,141.63,,184.11,65,,147.288,Percent of Total Billed Charges,65% of Total Billed Charges,192.61,68,,154.088,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,56.65,20,,45.32,Percent of Total Billed Charges,20% of Total Billed Charges,56.65,20,,45.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.65,20,,45.32,Percent of Total Billed Charges,20% of Total Billed Charges,56.65,20,,45.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.11,65,,147.288,Percent of Total Billed Charges,65% of Total Billed Charges,184.11,65,,147.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,312,
ER NOSE HEM/POST W/PKS,1031113,CDM,450,RC,30905,HCPCS,Outpatient,,,487.19,243.60,,316.67,65,,253.336,Percent of Total Billed Charges,65% of Total Billed Charges,331.29,68,,265.032,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,97.44,20,,77.952,Percent of Total Billed Charges,20% of Total Billed Charges,97.44,20,,77.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.44,20,,77.952,Percent of Total Billed Charges,20% of Total Billed Charges,97.44,20,,77.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.67,65,,253.336,Percent of Total Billed Charges,65% of Total Billed Charges,316.67,65,,253.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,331.29,
ER LUMBAR PUNCTURE,1031115,CDM,450,RC,62270,HCPCS,Outpatient,,,545.9,272.95,,354.84,65,,283.872,Percent of Total Billed Charges,65% of Total Billed Charges,371.21,68,,296.968,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,109.18,20,,87.344,Percent of Total Billed Charges,20% of Total Billed Charges,109.18,20,,87.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.18,20,,87.344,Percent of Total Billed Charges,20% of Total Billed Charges,109.18,20,,87.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,354.84,65,,283.872,Percent of Total Billed Charges,65% of Total Billed Charges,354.84,65,,283.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,371.21,
ER THORACENTESIS,1031117,CDM,450,RC,32554,HCPCS,Outpatient,,,450.11,225.06,,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,306.07,68,,244.856,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,312,
ER PARACENTESIS,1031119,CDM,450,RC,49083,HCPCS,Outpatient,,,450.11,225.06,,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,306.07,68,,244.856,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665,
PARACENTESIS W/O GUIDANCE,1031120,CDM,450,RC,49082,HCPCS,Outpatient,,,450.11,225.06,,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,306.07,68,,244.856,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,90.02,20,,72.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,292.57,65,,234.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665,
ER TRACHEOSTOMY,1031121,CDM,450,RC,31603,HCPCS,Outpatient,,,1121.67,560.84,,729.09,65,,583.272,Percent of Total Billed Charges,65% of Total Billed Charges,762.74,68,,610.192,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,224.33,20,,179.464,Percent of Total Billed Charges,20% of Total Billed Charges,224.33,20,,179.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.33,20,,179.464,Percent of Total Billed Charges,20% of Total Billed Charges,224.33,20,,179.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,729.09,65,,583.272,Percent of Total Billed Charges,65% of Total Billed Charges,729.09,65,,583.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,762.74,
ER PERIPHERAL NERV BLK,1031123,CDM,450,RC,64450,HCPCS,Outpatient,,,266.77,133.39,,173.4,65,,138.72,Percent of Total Billed Charges,65% of Total Billed Charges,181.4,68,,145.12,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.35,20,,42.68,Percent of Total Billed Charges,20% of Total Billed Charges,53.35,20,,42.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.35,20,,42.68,Percent of Total Billed Charges,20% of Total Billed Charges,53.35,20,,42.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.4,65,,138.72,Percent of Total Billed Charges,65% of Total Billed Charges,173.4,65,,138.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.35,296,
ER THROMBOLYSIS,1031125,CDM,450,RC,92977,HCPCS,Outpatient,,,854.9,427.45,,555.69,65,,444.552,Percent of Total Billed Charges,65% of Total Billed Charges,581.33,68,,465.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.98,20,,136.784,Percent of Total Billed Charges,20% of Total Billed Charges,170.98,20,,136.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.98,20,,136.784,Percent of Total Billed Charges,20% of Total Billed Charges,170.98,20,,136.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.69,65,,444.552,Percent of Total Billed Charges,65% of Total Billed Charges,555.69,65,,444.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,581.33,
ER CENTRAL VENOUS CATH INSERT,1031127,CDM,450,RC,36569,HCPCS,Outpatient,,,804.43,402.22,,522.88,65,,418.304,Percent of Total Billed Charges,65% of Total Billed Charges,547.01,68,,437.608,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,160.89,20,,128.712,Percent of Total Billed Charges,20% of Total Billed Charges,160.89,20,,128.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.89,20,,128.712,Percent of Total Billed Charges,20% of Total Billed Charges,160.89,20,,128.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,522.88,65,,418.304,Percent of Total Billed Charges,65% of Total Billed Charges,522.88,65,,418.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,547.01,
ER DELIVERY OF PLACENTA,1031129,CDM,450,RC,59414,HCPCS,Outpatient,,,1734.52,867.26,,1127.44,65,,901.952,Percent of Total Billed Charges,65% of Total Billed Charges,1179.47,68,,943.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.9,20,,277.52,Percent of Total Billed Charges,20% of Total Billed Charges,346.9,20,,277.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.9,20,,277.52,Percent of Total Billed Charges,20% of Total Billed Charges,346.9,20,,277.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1127.44,65,,901.952,Percent of Total Billed Charges,65% of Total Billed Charges,1127.44,65,,901.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1478,
ER VAGINAL DELIVERY,1031131,CDM,450,RC,59409,HCPCS,Outpatient,,,2156.82,1078.41,,1401.93,65,,1121.544,Percent of Total Billed Charges,65% of Total Billed Charges,1466.64,68,,1173.312,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,431.36,20,,345.088,Percent of Total Billed Charges,20% of Total Billed Charges,431.36,20,,345.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,431.36,20,,345.088,Percent of Total Billed Charges,20% of Total Billed Charges,431.36,20,,345.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1401.93,65,,1121.544,Percent of Total Billed Charges,65% of Total Billed Charges,1401.93,65,,1121.544,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1478,
ER THORASCOSTOMY,1031133,CDM,450,RC,32557,HCPCS,Outpatient,,,670.53,335.27,,435.84,65,,348.672,Percent of Total Billed Charges,65% of Total Billed Charges,455.96,68,,364.768,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.11,20,,107.288,Percent of Total Billed Charges,20% of Total Billed Charges,134.11,20,,107.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.11,20,,107.288,Percent of Total Billed Charges,20% of Total Billed Charges,134.11,20,,107.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,435.84,65,,348.672,Percent of Total Billed Charges,65% of Total Billed Charges,435.84,65,,348.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,455.96,
GASTROSTOMY TUBE CHG,1031135,CDM,450,RC,,,Outpatient,,,207.03,103.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.46,35,,57.968,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,134.57,
ER DISLOC FINGER CL FX,1031137,CDM,450,RC,26770,HCPCS,Outpatient,,,298.7,149.35,,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,203.12,68,,162.496,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,203.12,
ER DISLOC TOE CL FX,1031139,CDM,450,RC,28660,HCPCS,Outpatient,,,164.8,82.40,,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,112.06,68,,89.648,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,178,
ER WR COMP EA ADD 5 CM,1031141,CDM,450,RC,,,Outpatient,,,113.3,56.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,35,,31.728,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,73.65,
ER WR COMPLEX SCALP EXT,1031143,CDM,450,RC,,,Outpatient,,,370.8,185.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.16,20,,59.328,Percent of Total Billed Charges,20% of Total Billed Charges,74.16,20,,59.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.16,20,,59.328,Percent of Total Billed Charges,20% of Total Billed Charges,74.16,20,,59.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.02,65,,192.816,Percent of Total Billed Charges,65% of Total Billed Charges,241.02,65,,192.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.78,35,,103.824,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,241.02,
ER APP SPLINT POSTERIOR,1031145,CDM,271,RC,,,Outpatient,,,226.6,113.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,147.29,
APPLICATION UNNA BOOT,1031147,CDM,450,RC,29580,HCPCS,Outpatient,,,111.24,55.62,,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,75.64,68,,60.512,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.25,178,
RP SIMPLE 2.5 OR < FACE,1031151,CDM,450,RC,12011,HCPCS,Outpatient,,,219.39,109.70,,142.6,65,,114.08,Percent of Total Billed Charges,65% of Total Billed Charges,149.19,68,,119.352,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.88,20,,35.104,Percent of Total Billed Charges,20% of Total Billed Charges,43.88,20,,35.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.88,20,,35.104,Percent of Total Billed Charges,20% of Total Billed Charges,43.88,20,,35.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.6,65,,114.08,Percent of Total Billed Charges,65% of Total Billed Charges,142.6,65,,114.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.88,178,
ER RP SIMPLE 12.6-20CM,1031153,CDM,450,RC,12005,HCPCS,Outpatient,,,223.51,111.76,,145.28,65,,116.224,Percent of Total Billed Charges,65% of Total Billed Charges,151.99,68,,121.592,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,44.7,20,,35.76,Percent of Total Billed Charges,20% of Total Billed Charges,44.7,20,,35.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.7,20,,35.76,Percent of Total Billed Charges,20% of Total Billed Charges,44.7,20,,35.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.28,65,,116.224,Percent of Total Billed Charges,65% of Total Billed Charges,145.28,65,,116.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.7,419,
ER RP SIMPLE >30CM,1031155,CDM,450,RC,,,Outpatient,,,416.12,208.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.22,20,,66.576,Percent of Total Billed Charges,20% of Total Billed Charges,83.22,20,,66.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.22,20,,66.576,Percent of Total Billed Charges,20% of Total Billed Charges,83.22,20,,66.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.48,65,,216.384,Percent of Total Billed Charges,65% of Total Billed Charges,270.48,65,,216.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.64,35,,116.512,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,270.48,
ER RP INTERM UP TO 30CM,1031157,CDM,450,RC,,,Outpatient,,,558.26,279.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.65,20,,89.32,Percent of Total Billed Charges,20% of Total Billed Charges,111.65,20,,89.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.65,20,,89.32,Percent of Total Billed Charges,20% of Total Billed Charges,111.65,20,,89.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.87,65,,290.296,Percent of Total Billed Charges,65% of Total Billed Charges,362.87,65,,290.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.39,35,,156.312,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,362.87,
WOUND EXPLO CHEST,1031159,CDM,450,RC,20101,HCPCS,Outpatient,,,1992.37,996.19,,1295.04,65,,1036.032,Percent of Total Billed Charges,65% of Total Billed Charges,1354.81,68,,1083.848,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.47,20,,318.776,Percent of Total Billed Charges,20% of Total Billed Charges,398.47,20,,318.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.47,20,,318.776,Percent of Total Billed Charges,20% of Total Billed Charges,398.47,20,,318.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1295.04,65,,1036.032,Percent of Total Billed Charges,65% of Total Billed Charges,1295.04,65,,1036.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1354.81,
ART/ASP/IN MAJ JOINT,1031161,CDM,450,RC,20610,HCPCS,Outpatient,,,208.06,104.03,,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,141.48,68,,113.184,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,178,
I O NEEDLE PLACEMENT,1031163,CDM,450,RC,36680,HCPCS,Outpatient,,,803.4,401.70,,522.21,65,,417.768,Percent of Total Billed Charges,65% of Total Billed Charges,546.31,68,,437.048,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.68,20,,128.544,Percent of Total Billed Charges,20% of Total Billed Charges,160.68,20,,128.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.68,20,,128.544,Percent of Total Billed Charges,20% of Total Billed Charges,160.68,20,,128.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,522.21,65,,417.768,Percent of Total Billed Charges,65% of Total Billed Charges,522.21,65,,417.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,546.31,
EAR IRRIGATION,1031164,CDM,450,RC,69209,HCPCS,Outpatient,,,47.9,23.95,,31.14,65,,24.912,Percent of Total Billed Charges,65% of Total Billed Charges,32.57,68,,26.056,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.58,20,,7.664,Percent of Total Billed Charges,20% of Total Billed Charges,9.58,20,,7.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.58,20,,7.664,Percent of Total Billed Charges,20% of Total Billed Charges,9.58,20,,7.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.14,65,,24.912,Percent of Total Billed Charges,65% of Total Billed Charges,31.14,65,,24.912,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.58,178,
ER-BLOOD TRANSFUSION,1031927,CDM,391,RC,36430,HCPCS,Outpatient,,,325.48,162.74,,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,221.33,68,,177.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,65.1,20,,52.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,211.56,65,,169.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,221.33,
GASTROSTOMY TUBE CHG,1031931,CDM,450,RC,43762,HCPCS,Outpatient,,,207.03,103.52,,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,140.78,68,,112.624,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,312,
NASOGASTRIC TUBE PLACEMENT,1031932,CDM,450,RC,43762,HCPCS,Outpatient,,,379,189.50,,246.35,65,,197.08,Percent of Total Billed Charges,65% of Total Billed Charges,257.72,68,,206.176,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,75.8,20,,60.64,Percent of Total Billed Charges,20% of Total Billed Charges,75.8,20,,60.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.8,20,,60.64,Percent of Total Billed Charges,20% of Total Billed Charges,75.8,20,,60.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.35,65,,197.08,Percent of Total Billed Charges,65% of Total Billed Charges,246.35,65,,197.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,312,
IV INF/MED ADD HR - OP,1031966,CDM,260,RC,96366,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
ER OTHER OUTPATIENT VISIT,1031968,CDM,761,RC,99211,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,53.67,
ER DRESSING CHANGE MINOR,1032968,CDM,761,RC,99211,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,53.67,
ER- OTHER OP VISIT,1033968,CDM,761,RC,99211,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,53.67,
OR- OTHER OR VISIT,1033969,CDM,761,RC,99211,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,53.67,
CERVICAL COLLAR-ADULT,1050669,CDM,274,RC,L0174,HCPCS,Outpatient,,,61.18,30.59,,39.77,65,,31.816,Percent of Total Billed Charges,65% of Total Billed Charges,41.6,68,,33.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.94,80,,39.152,Percent of Total Billed Charges,80% of Total Billed Charges,52,85,,41.6,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,52,
DISLOC TOE CL TX,1140967,CDM,981,RC,28540,HCPCS,Outpatient,,,282.22,141.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,194.89,110,,,Fee Schedule,110% of Multiplan Fee Schedule,194.89,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,224.12,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,161.62,100,,,Case Rate,Pays Based on per visit rate,109.02,100,,,Fee Schedule,100% of FL Medicaid Rate,109.02,100,,,Fee Schedule,100% of FL Medicaid rate,109.02,224.12,
PHY-LEVEL I WITH P,1141009,CDM,981,RC,99281,HCPCS,Outpatient,,,78.28,39.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,26.25,109,,,Fee Schedule,109% of Multiplan Fee Schedule,26.25,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.72,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,63.66,100,,,Case Rate,Pays Based on per visit rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid rate,14.72,459,
PHY-LEVEL II WITH P,1141011,CDM,981,RC,99282,HCPCS,Outpatient,,,106.09,53.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,93.59,109,,,Fee Schedule,109% of Multiplan Fee Schedule,93.59,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,53.57,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,78.06,100,,,Case Rate,Pays Based on per visit rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid rate,29.76,459,
PHY-LEVEL III WI PR,1141013,CDM,981,RC,99283,HCPCS,Outpatient,,,169.95,84.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,160.2,109,,,Fee Schedule,109% of Multiplan Fee Schedule,160.2,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,91.21,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,94.1,100,,,Case Rate,Pays Based on per visit rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid rate,45.8,459,
PHY-LEVEL IV WITH P,1141015,CDM,981,RC,99284,HCPCS,Outpatient,,,239.99,120.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,270.47,109,,,Fee Schedule,109% of Multiplan Fee Schedule,270.47,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,155.25,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,132.45,100,,,Case Rate,Pays Based on per visit rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid rate,84.15,459,
PHY-LEVELV WPROCEDUR,1141017,CDM,981,RC,99285,HCPCS,Outpatient,,,356.38,178.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,393.31,109,,,Fee Schedule,109% of Multiplan Fee Schedule,393.31,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,224.97,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,170.53,100,,,Case Rate,Pays Based on per visit rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid rate,122.23,459,
CRITICAL CARE 1ST HR,1141019,CDM,981,RC,99291,HCPCS,Outpatient,,,412,206.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,471.91,109,,,Fee Schedule,109% of Multiplan Fee Schedule,471.91,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,270.17,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,194.37,100,,,Case Rate,Pays Based on per visit rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid rate,146.07,471.91,
PHY LEVEL I,1141021,CDM,981,RC,99281,HCPCS,Outpatient,,,78.28,39.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,26.25,109,,,Fee Schedule,109% of Multiplan Fee Schedule,26.25,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.72,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,63.66,100,,,Case Rate,Pays Based on per visit rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid rate,14.72,459,
PHY-LEVEL II,1141031,CDM,981,RC,99282,HCPCS,Outpatient,,,106.09,53.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,93.59,109,,,Fee Schedule,109% of Multiplan Fee Schedule,93.59,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,53.57,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,78.06,100,,,Case Rate,Pays Based on per visit rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid rate,29.76,459,
PHY-LEVEL III,1141059,CDM,981,RC,99283,HCPCS,Outpatient,,,169.95,84.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,160.2,109,,,Fee Schedule,109% of Multiplan Fee Schedule,160.2,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,91.21,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,94.1,100,,,Case Rate,Pays Based on per visit rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid rate,45.8,459,
PHY-CRITICAL 90MIN,1141075,CDM,981,RC,99292,HCPCS,Outpatient,,,203.94,101.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,237.89,109,,,Fee Schedule,109% of Multiplan Fee Schedule,237.89,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,136.49,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,121.68,100,,,Case Rate,Pays Based on per visit rate,73.38,100,,,Fee Schedule,100% of FL Medicaid Rate,73.38,100,,,Fee Schedule,100% of FL Medicaid rate,73.38,459,
PHY-LEVEL IV,1141083,CDM,981,RC,99284,HCPCS,Outpatient,,,239.99,120.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,270.47,109,,,Fee Schedule,109% of Multiplan Fee Schedule,270.47,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,155.25,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,132.45,100,,,Case Rate,Pays Based on per visit rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid rate,84.15,459,
PHY-LEVEL V,1141103,CDM,981,RC,99285,HCPCS,Outpatient,,,356.38,178.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,393.31,109,,,Fee Schedule,109% of Multiplan Fee Schedule,393.31,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,224.97,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,170.53,100,,,Case Rate,Pays Based on per visit rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid rate,122.23,459,
PHY-CRITICAL30-90MIN,1141109,CDM,981,RC,99291,HCPCS,Outpatient,,,412,206.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,471.91,109,,,Fee Schedule,109% of Multiplan Fee Schedule,471.91,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,270.17,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,194.37,100,,,Case Rate,Pays Based on per visit rate,146.07,100,,,Fee Schedule,100% of FL Medicaid Rate,146.07,100,,,Fee Schedule,100% of FL Medicaid rate,146.07,471.91,
INSERT NON-TUNNEL CV CATH,2200078,CDM,360,RC,36556,HCPCS,Outpatient,,,3552.5,1776.25,,2309.13,65,,1847.304,Percent of Total Billed Charges,65% of Total Billed Charges,2415.7,68,,1932.56,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,710.5,20,,568.4,Percent of Total Billed Charges,20% of Total Billed Charges,710.5,20,,568.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,710.5,20,,568.4,Percent of Total Billed Charges,20% of Total Billed Charges,710.5,20,,568.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2309.13,65,,1847.304,Percent of Total Billed Charges,65% of Total Billed Charges,2309.13,65,,1847.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2415.7,
THORACENTESIS NEEDLE/CATH W/IMAGING,2200080,CDM,360,RC,32555,HCPCS,Outpatient,,,756.02,378.01,,491.41,65,,393.128,Percent of Total Billed Charges,65% of Total Billed Charges,514.09,68,,411.272,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,151.2,20,,120.96,Percent of Total Billed Charges,20% of Total Billed Charges,151.2,20,,120.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.2,20,,120.96,Percent of Total Billed Charges,20% of Total Billed Charges,151.2,20,,120.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.41,65,,393.128,Percent of Total Billed Charges,65% of Total Billed Charges,491.41,65,,393.128,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,514.09,
KETAMINE 50MG/ML,2260001,CDM,636,RC,J3490,HCPCS,Outpatient,,,59.94,29.97,,,,,,Other,Not Seperately Reimbuasble,40.76,68,,32.608,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.99,20,,9.592,Percent of Total Billed Charges,20% of Total Billed Charges,11.99,20,,9.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.99,20,,9.592,Percent of Total Billed Charges,20% of Total Billed Charges,11.99,20,,9.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.95,80,,38.36,Percent of Total Billed Charges,80% of Total Billed Charges,50.95,85,,40.76,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.99,50.95,
ANTICOAG MGMT,2260004,CDM,260,RC,93793,HCPCS,Outpatient,,,99.07,49.54,,64.4,65,,51.52,Percent of Total Billed Charges,65% of Total Billed Charges,67.37,68,,53.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.81,20,,15.848,Percent of Total Billed Charges,20% of Total Billed Charges,19.81,20,,15.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.81,20,,15.848,Percent of Total Billed Charges,20% of Total Billed Charges,19.81,20,,15.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.4,65,,51.52,Percent of Total Billed Charges,65% of Total Billed Charges,64.4,65,,51.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.81,67.37,
IV INFUSION THERAPY INITIAL,2260005,CDM,260,RC,96360,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,133.08,
INJ/IV PSH NEW/SQ MED,2260006,CDM,260,RC,96375,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
PULSE OXEMETER,2260007,CDM,271,RC,,,Outpatient,,,70.04,35.02,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,53.67,
VIDEO MONITOR,2260009,CDM,271,RC,,,Outpatient,,,233.81,116.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.76,20,,37.408,Percent of Total Billed Charges,20% of Total Billed Charges,46.76,20,,37.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.76,20,,37.408,Percent of Total Billed Charges,20% of Total Billed Charges,46.76,20,,37.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.98,65,,121.584,Percent of Total Billed Charges,65% of Total Billed Charges,151.98,65,,121.584,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.76,151.98,
FIBEROPTIC SCOPE,2260011,CDM,271,RC,,,Outpatient,,,185.76,92.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.15,20,,29.72,Percent of Total Billed Charges,20% of Total Billed Charges,37.15,20,,29.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.15,20,,29.72,Percent of Total Billed Charges,20% of Total Billed Charges,37.15,20,,29.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.74,65,,96.592,Percent of Total Billed Charges,65% of Total Billed Charges,120.74,65,,96.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.15,120.74,
TOURNIQUET EQUIP,2260015,CDM,271,RC,,,Outpatient,,,77.25,38.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,53.67,
STERIS SYSTEM EQUIP,2260019,CDM,271,RC,,,Outpatient,,,177.16,88.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.43,20,,28.344,Percent of Total Billed Charges,20% of Total Billed Charges,35.43,20,,28.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.43,20,,28.344,Percent of Total Billed Charges,20% of Total Billed Charges,35.43,20,,28.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.15,65,,92.12,Percent of Total Billed Charges,65% of Total Billed Charges,115.15,65,,92.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.43,115.15,
CARDIAC MONITOR,2260043,CDM,271,RC,,,Outpatient,,,103,51.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,66.95,
BALLOON DILATORS,2260049,CDM,272,RC,,,Outpatient,,,669.5,334.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,20,,107.12,Percent of Total Billed Charges,20% of Total Billed Charges,133.9,20,,107.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,20,,107.12,Percent of Total Billed Charges,20% of Total Billed Charges,133.9,20,,107.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,435.18,65,,348.144,Percent of Total Billed Charges,65% of Total Billed Charges,435.18,65,,348.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,435.18,
BIOPSY FORCEP LARGE,2260051,CDM,272,RC,,,Outpatient,,,143.17,71.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,93.06,
SNARES,2260053,CDM,272,RC,,,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,100.43,
GOLD PROBE,2260055,CDM,272,RC,,,Outpatient,,,597.4,298.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.48,20,,95.584,Percent of Total Billed Charges,20% of Total Billed Charges,119.48,20,,95.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.48,20,,95.584,Percent of Total Billed Charges,20% of Total Billed Charges,119.48,20,,95.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.31,65,,310.648,Percent of Total Billed Charges,65% of Total Billed Charges,388.31,65,,310.648,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,388.31,
CAUTERY GROUNDING PA,2260057,CDM,272,RC,,,Outpatient,,,46.35,23.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,53.67,
PREP TRAY,2260079,CDM,272,RC,,,Outpatient,,,32.14,16.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.43,20,,5.144,Percent of Total Billed Charges,20% of Total Billed Charges,6.43,20,,5.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.43,20,,5.144,Percent of Total Billed Charges,20% of Total Billed Charges,6.43,20,,5.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.89,65,,16.712,Percent of Total Billed Charges,65% of Total Billed Charges,20.89,65,,16.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.43,53.67,
SUTURE GROUP 2,2260085,CDM,272,RC,,,Outpatient,,,66.69,33.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.34,20,,10.672,Percent of Total Billed Charges,20% of Total Billed Charges,13.34,20,,10.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.34,20,,10.672,Percent of Total Billed Charges,20% of Total Billed Charges,13.34,20,,10.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.35,65,,34.68,Percent of Total Billed Charges,65% of Total Billed Charges,43.35,65,,34.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.34,53.67,
SUCTION SUPPLIES,2260099,CDM,272,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
OPERATING ROOM,2260100,CDM,360,RC,,,Outpatient,,,1545,772.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540.75,35,,432.6,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1004.25,
O2 MASK OR CANNULA,2260111,CDM,272,RC,,,Outpatient,,,6.85,3.43,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,20,,1.096,Percent of Total Billed Charges,20% of Total Billed Charges,1.37,20,,1.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,20,,1.096,Percent of Total Billed Charges,20% of Total Billed Charges,1.37,20,,1.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.45,65,,3.56,Percent of Total Billed Charges,65% of Total Billed Charges,4.45,65,,3.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,53.67,
ELECTRODES TRIPLE,2260117,CDM,272,RC,,,Outpatient,,,61.18,30.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.77,65,,31.816,Percent of Total Billed Charges,65% of Total Billed Charges,39.77,65,,31.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,53.67,
INJECTOR NEEDLES,2260131,CDM,272,RC,,,Outpatient,,,323.01,161.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.6,20,,51.68,Percent of Total Billed Charges,20% of Total Billed Charges,64.6,20,,51.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.6,20,,51.68,Percent of Total Billed Charges,20% of Total Billed Charges,64.6,20,,51.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.96,65,,167.968,Percent of Total Billed Charges,65% of Total Billed Charges,209.96,65,,167.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,209.96,
EXTREMITY PAK,2260139,CDM,272,RC,,,Outpatient,,,254.93,127.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.7,65,,132.56,Percent of Total Billed Charges,65% of Total Billed Charges,165.7,65,,132.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,165.7,
SUCTION TIP YANKER,2260143,CDM,272,RC,,,Outpatient,,,14.11,7.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.17,65,,7.336,Percent of Total Billed Charges,65% of Total Billed Charges,9.17,65,,7.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,53.67,
POLYPECTOMY SNARE,2260147,CDM,272,RC,,,Outpatient,,,135.96,67.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.19,20,,21.752,Percent of Total Billed Charges,20% of Total Billed Charges,27.19,20,,21.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.19,20,,21.752,Percent of Total Billed Charges,20% of Total Billed Charges,27.19,20,,21.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.37,65,,70.696,Percent of Total Billed Charges,65% of Total Billed Charges,88.37,65,,70.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.19,88.37,
RAYTEX GAUZE,2260149,CDM,272,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
LIGATOR BAND,2260165,CDM,272,RC,,,Outpatient,,,875.5,437.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.1,20,,140.08,Percent of Total Billed Charges,20% of Total Billed Charges,175.1,20,,140.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.1,20,,140.08,Percent of Total Billed Charges,20% of Total Billed Charges,175.1,20,,140.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,569.08,65,,455.264,Percent of Total Billed Charges,65% of Total Billed Charges,569.08,65,,455.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,569.08,
ENDO SPOT PER 1 MG,2260169,CDM,636,RC,Q9968,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.22,80,,55.376,Percent of Total Billed Charges,80% of Total Billed Charges,73.54,85,,58.832,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,73.54,
RESOLUTION CLIP,2260171,CDM,278,RC,,,Outpatient,,,782.8,391.40,,,,,,Other,Not Seperately Reimbuasble,532.31,68,,425.848,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.56,20,,125.248,Percent of Total Billed Charges,20% of Total Billed Charges,156.56,20,,125.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.56,20,,125.248,Percent of Total Billed Charges,20% of Total Billed Charges,156.56,20,,125.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,626.24,80,,500.992,Percent of Total Billed Charges,80% of Total Billed Charges,665.38,85,,532.304,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665.38,
PEG KITS,2260177,CDM,272,RC,,,Outpatient,,,474.83,237.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.97,20,,75.976,Percent of Total Billed Charges,20% of Total Billed Charges,94.97,20,,75.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.97,20,,75.976,Percent of Total Billed Charges,20% of Total Billed Charges,94.97,20,,75.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.64,65,,246.912,Percent of Total Billed Charges,65% of Total Billed Charges,308.64,65,,246.912,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,308.64,
BIOPSY FORCEP JUMBO,2260179,CDM,272,RC,,,Outpatient,,,360.5,180.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.1,20,,57.68,Percent of Total Billed Charges,20% of Total Billed Charges,72.1,20,,57.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.1,20,,57.68,Percent of Total Billed Charges,20% of Total Billed Charges,72.1,20,,57.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.33,65,,187.464,Percent of Total Billed Charges,65% of Total Billed Charges,234.33,65,,187.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,234.33,
HOT BIOPSY FORCEP,2260181,CDM,272,RC,,,Outpatient,,,141.11,70.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.72,65,,73.376,Percent of Total Billed Charges,65% of Total Billed Charges,91.72,65,,73.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.22,91.72,
PLASTIC TRAY,2260187,CDM,272,RC,,,Outpatient,,,131.33,65.67,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.27,20,,21.016,Percent of Total Billed Charges,20% of Total Billed Charges,26.27,20,,21.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.27,20,,21.016,Percent of Total Billed Charges,20% of Total Billed Charges,26.27,20,,21.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.36,65,,68.288,Percent of Total Billed Charges,65% of Total Billed Charges,85.36,65,,68.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.27,85.36,
SCALPEL W/HANDLE,2260189,CDM,272,RC,,,Outpatient,,,7.73,3.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,20,,1.24,Percent of Total Billed Charges,20% of Total Billed Charges,1.55,20,,1.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,20,,1.24,Percent of Total Billed Charges,20% of Total Billed Charges,1.55,20,,1.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,65,,4.016,Percent of Total Billed Charges,65% of Total Billed Charges,5.02,65,,4.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,53.67,
POLY TRAP,2260191,CDM,272,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
INFLATION SYRINGE,2260193,CDM,272,RC,,,Outpatient,,,329.6,164.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.92,20,,52.736,Percent of Total Billed Charges,20% of Total Billed Charges,65.92,20,,52.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.92,20,,52.736,Percent of Total Billed Charges,20% of Total Billed Charges,65.92,20,,52.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.24,65,,171.392,Percent of Total Billed Charges,65% of Total Billed Charges,214.24,65,,171.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,214.24,
TRAY SUTURE,2260195,CDM,272,RC,,,Outpatient,,,65.71,32.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.71,65,,34.168,Percent of Total Billed Charges,65% of Total Billed Charges,42.71,65,,34.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,53.67,
CAT INRTOCULAR LENS,2260199,CDM,276,RC,,,Outpatient,,,309,154.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.2,80,,197.76,Percent of Total Billed Charges,80% of Total Billed Charges,262.65,85,,210.12,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,262.65,
YAG LASER SURGERY,2260205,CDM,360,RC,66821,HCPCS,Outpatient,,,1215.4,607.70,,790.01,65,,632.008,Percent of Total Billed Charges,65% of Total Billed Charges,826.47,68,,661.176,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,243.08,20,,194.464,Percent of Total Billed Charges,20% of Total Billed Charges,243.08,20,,194.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.08,20,,194.464,Percent of Total Billed Charges,20% of Total Billed Charges,243.08,20,,194.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790.01,65,,632.008,Percent of Total Billed Charges,65% of Total Billed Charges,790.01,65,,632.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,826.47,
SURGERY 15 MINUTES,2260207,CDM,360,RC,,,Outpatient,,,310,155.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.5,35,,86.8,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,201.5,
SURGERY 15 MINUTES,2260213,CDM,360,RC,,,Outpatient,,,269.86,134.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.97,20,,43.176,Percent of Total Billed Charges,20% of Total Billed Charges,53.97,20,,43.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.97,20,,43.176,Percent of Total Billed Charges,20% of Total Billed Charges,53.97,20,,43.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.41,65,,140.328,Percent of Total Billed Charges,65% of Total Billed Charges,175.41,65,,140.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.45,35,,75.56,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,175.41,
SURGERY 30 MINUTES,2260219,CDM,361,RC,,,Outpatient,,,622,311.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.4,20,,99.52,Percent of Total Billed Charges,20% of Total Billed Charges,124.4,20,,99.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.4,20,,99.52,Percent of Total Billed Charges,20% of Total Billed Charges,124.4,20,,99.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,404.3,65,,323.44,Percent of Total Billed Charges,65% of Total Billed Charges,404.3,65,,323.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.7,35,,174.16,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,404.3,
SURGERY 1 HR,2260221,CDM,361,RC,,,Outpatient,,,1243,621.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.6,20,,198.88,Percent of Total Billed Charges,20% of Total Billed Charges,248.6,20,,198.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.6,20,,198.88,Percent of Total Billed Charges,20% of Total Billed Charges,248.6,20,,198.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,807.95,65,,646.36,Percent of Total Billed Charges,65% of Total Billed Charges,807.95,65,,646.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,435.05,35,,348.04,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,807.95,
SIGMOID W/BIOPSY,2260225,CDM,750,RC,45331,HCPCS,Outpatient,,,1307.07,653.54,,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,888.81,68,,711.048,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,888.81,
EGD,2260227,CDM,750,RC,43235,HCPCS,Outpatient,,,1257.63,628.82,,817.46,65,,653.968,Percent of Total Billed Charges,65% of Total Billed Charges,855.19,68,,684.152,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,251.53,20,,201.224,Percent of Total Billed Charges,20% of Total Billed Charges,251.53,20,,201.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,251.53,20,,201.224,Percent of Total Billed Charges,20% of Total Billed Charges,251.53,20,,201.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,817.46,65,,653.968,Percent of Total Billed Charges,65% of Total Billed Charges,817.46,65,,653.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,855.19,
EGD DISCONTINUED,2260228,CDM,750,RC,43235,HCPCS,Outpatient,,,721,360.50,,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,490.28,68,,392.224,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665,
EGD WITH BIOPSY,2260229,CDM,750,RC,43239,HCPCS,Outpatient,,,2296.25,1148.13,,1492.56,65,,1194.048,Percent of Total Billed Charges,65% of Total Billed Charges,1561.45,68,,1249.16,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,459.25,20,,367.4,Percent of Total Billed Charges,20% of Total Billed Charges,459.25,20,,367.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459.25,20,,367.4,Percent of Total Billed Charges,20% of Total Billed Charges,459.25,20,,367.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1492.56,65,,1194.048,Percent of Total Billed Charges,65% of Total Billed Charges,1492.56,65,,1194.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1561.45,
G-TUBE REPLACEMENT,2260231,CDM,750,RC,43762,HCPCS,Outpatient,,,204.97,102.49,,133.23,65,,106.584,Percent of Total Billed Charges,65% of Total Billed Charges,139.38,68,,111.504,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,40.99,20,,32.792,Percent of Total Billed Charges,20% of Total Billed Charges,40.99,20,,32.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.99,20,,32.792,Percent of Total Billed Charges,20% of Total Billed Charges,40.99,20,,32.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.23,65,,106.584,Percent of Total Billed Charges,65% of Total Billed Charges,133.23,65,,106.584,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.99,312,
COLONOSCOPY DIAGNOST,2260235,CDM,750,RC,45378,HCPCS,Outpatient,,,2174.75,1087.38,,1413.59,65,,1130.872,Percent of Total Billed Charges,65% of Total Billed Charges,1478.83,68,,1183.064,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,434.95,20,,347.96,Percent of Total Billed Charges,20% of Total Billed Charges,434.95,20,,347.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.95,20,,347.96,Percent of Total Billed Charges,20% of Total Billed Charges,434.95,20,,347.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1413.59,65,,1130.872,Percent of Total Billed Charges,65% of Total Billed Charges,1413.59,65,,1130.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1478.83,
COLONOSCOPY/BIOPSY C,2260237,CDM,750,RC,45380,HCPCS,Outpatient,,,2532.75,1266.38,,1646.29,65,,1317.032,Percent of Total Billed Charges,65% of Total Billed Charges,1722.27,68,,1377.816,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,506.55,20,,405.24,Percent of Total Billed Charges,20% of Total Billed Charges,506.55,20,,405.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.55,20,,405.24,Percent of Total Billed Charges,20% of Total Billed Charges,506.55,20,,405.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1646.29,65,,1317.032,Percent of Total Billed Charges,65% of Total Billed Charges,1646.29,65,,1317.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1722.27,
COLONOS W/BLEEDING,2260239,CDM,750,RC,45382,HCPCS,Outpatient,,,1472.9,736.45,,957.39,65,,765.912,Percent of Total Billed Charges,65% of Total Billed Charges,1001.57,68,,801.256,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,294.58,20,,235.664,Percent of Total Billed Charges,20% of Total Billed Charges,294.58,20,,235.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.58,20,,235.664,Percent of Total Billed Charges,20% of Total Billed Charges,294.58,20,,235.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,957.39,65,,765.912,Percent of Total Billed Charges,65% of Total Billed Charges,957.39,65,,765.912,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1001.57,
COL/POLYP REM SNA/CU,2260245,CDM,750,RC,45385,HCPCS,Outpatient,,,3389.5,1694.75,,2203.18,65,,1762.544,Percent of Total Billed Charges,65% of Total Billed Charges,2304.86,68,,1843.888,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,677.9,20,,542.32,Percent of Total Billed Charges,20% of Total Billed Charges,677.9,20,,542.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,677.9,20,,542.32,Percent of Total Billed Charges,20% of Total Billed Charges,677.9,20,,542.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2203.18,65,,1762.544,Percent of Total Billed Charges,65% of Total Billed Charges,2203.18,65,,1762.544,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2304.86,
SIGMOID W/RM SNARE,2260247,CDM,750,RC,45338,HCPCS,Outpatient,,,1307.07,653.54,,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,888.81,68,,711.048,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,888.81,
SIGMOID W/REMOVAL,2260249,CDM,750,RC,45333,HCPCS,Outpatient,,,1307.07,653.54,,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,888.81,68,,711.048,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,888.81,
SIGMOID W/BLEEDING,2260251,CDM,750,RC,45334,HCPCS,Outpatient,,,1307.07,653.54,,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,888.81,68,,711.048,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,888.81,
GI DILATATION,2260253,CDM,750,RC,43249,HCPCS,Outpatient,,,2196.75,1098.38,,1427.89,65,,1142.312,Percent of Total Billed Charges,65% of Total Billed Charges,1493.79,68,,1195.032,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,439.35,20,,351.48,Percent of Total Billed Charges,20% of Total Billed Charges,439.35,20,,351.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.35,20,,351.48,Percent of Total Billed Charges,20% of Total Billed Charges,439.35,20,,351.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1427.89,65,,1142.312,Percent of Total Billed Charges,65% of Total Billed Charges,1427.89,65,,1142.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1493.79,
COLON/HIGH RISK SCRE,2260255,CDM,750,RC,G0105,HCPCS,Outpatient,,,1359.6,679.80,,883.74,65,,706.992,Percent of Total Billed Charges,65% of Total Billed Charges,924.53,68,,739.624,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,271.92,20,,217.536,Percent of Total Billed Charges,20% of Total Billed Charges,271.92,20,,217.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.92,20,,217.536,Percent of Total Billed Charges,20% of Total Billed Charges,271.92,20,,217.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,883.74,65,,706.992,Percent of Total Billed Charges,65% of Total Billed Charges,883.74,65,,706.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,924.53,
SIGMOIDOSCOPY,2260257,CDM,750,RC,G0104,HCPCS,Outpatient,,,1307.07,653.54,,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,888.81,68,,711.048,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,888.81,
OPERATING ROOM 1ST HOUR,2260258,CDM,360,RC,,,Outpatient,,,1684.05,842.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.81,20,,269.448,Percent of Total Billed Charges,20% of Total Billed Charges,336.81,20,,269.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.81,20,,269.448,Percent of Total Billed Charges,20% of Total Billed Charges,336.81,20,,269.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1094.63,65,,875.704,Percent of Total Billed Charges,65% of Total Billed Charges,1094.63,65,,875.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.42,35,,471.536,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1094.63,
COLONOSCOPY/SCREENIN,2260259,CDM,750,RC,G0121,HCPCS,Outpatient,,,1307.07,653.54,,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,888.81,68,,711.048,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,261.41,20,,209.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,849.6,65,,679.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,888.81,
OPERATING ROOM ADDL 1/2 HOUR,2260260,CDM,360,RC,,,Outpatient,,,840.48,420.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.1,20,,134.48,Percent of Total Billed Charges,20% of Total Billed Charges,168.1,20,,134.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.1,20,,134.48,Percent of Total Billed Charges,20% of Total Billed Charges,168.1,20,,134.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.31,65,,437.048,Percent of Total Billed Charges,65% of Total Billed Charges,546.31,65,,437.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.17,35,,235.336,Percent of Total Billed Charges,35% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,546.31,
RECOVERY ROOM 1ST HOUR,2260261,CDM,710,RC,,,Outpatient,,,620.06,310.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.01,20,,99.208,Percent of Total Billed Charges,20% of Total Billed Charges,124.01,20,,99.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.01,20,,99.208,Percent of Total Billed Charges,20% of Total Billed Charges,124.01,20,,99.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,403.04,65,,322.432,Percent of Total Billed Charges,65% of Total Billed Charges,403.04,65,,322.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,403.04,
RECOVERY ROOM ADDL 1/2 HOUR,2260262,CDM,710,RC,,,Outpatient,,,282.22,141.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.44,20,,45.152,Percent of Total Billed Charges,20% of Total Billed Charges,56.44,20,,45.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.44,20,,45.152,Percent of Total Billed Charges,20% of Total Billed Charges,56.44,20,,45.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.44,65,,146.752,Percent of Total Billed Charges,65% of Total Billed Charges,183.44,65,,146.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,183.44,
VASECTOMY UNILATERAL,2260266,CDM,360,RC,55250,HCPCS,Outpatient,,,1854,927.00,,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,1260.72,68,,1008.576,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1478,
FLEX SCREEN SIGMOID,2260267,CDM,750,RC,G0104,HCPCS,Outpatient,,,1144.33,572.17,,743.81,65,,595.048,Percent of Total Billed Charges,65% of Total Billed Charges,778.14,68,,622.512,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.87,20,,183.096,Percent of Total Billed Charges,20% of Total Billed Charges,228.87,20,,183.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.87,20,,183.096,Percent of Total Billed Charges,20% of Total Billed Charges,228.87,20,,183.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,743.81,65,,595.048,Percent of Total Billed Charges,65% of Total Billed Charges,743.81,65,,595.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,778.14,
VASECTOMY BILATERAL,2260268,CDM,360,RC,55250,HCPCS,Outpatient,,,1854,927.00,,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,1260.72,68,,1008.576,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1478,
COLON/W HOT BIOPSY,2260271,CDM,750,RC,44392,HCPCS,Outpatient,,,1418.31,709.16,,921.9,65,,737.52,Percent of Total Billed Charges,65% of Total Billed Charges,964.45,68,,771.56,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,283.66,20,,226.928,Percent of Total Billed Charges,20% of Total Billed Charges,283.66,20,,226.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.66,20,,226.928,Percent of Total Billed Charges,20% of Total Billed Charges,283.66,20,,226.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,921.9,65,,737.52,Percent of Total Billed Charges,65% of Total Billed Charges,921.9,65,,737.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,964.45,
EGD WITH POLYPECTOMY,2260273,CDM,750,RC,43239,HCPCS,Outpatient,,,1257.63,628.82,,817.46,65,,653.968,Percent of Total Billed Charges,65% of Total Billed Charges,855.19,68,,684.152,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,251.53,20,,201.224,Percent of Total Billed Charges,20% of Total Billed Charges,251.53,20,,201.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,251.53,20,,201.224,Percent of Total Billed Charges,20% of Total Billed Charges,251.53,20,,201.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,817.46,65,,653.968,Percent of Total Billed Charges,65% of Total Billed Charges,817.46,65,,653.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,855.19,
COLON DISCONTINUED,2260275,CDM,750,RC,45378,HCPCS,Outpatient,,,793.1,396.55,,515.52,65,,412.416,Percent of Total Billed Charges,65% of Total Billed Charges,539.31,68,,431.448,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,158.62,20,,126.896,Percent of Total Billed Charges,20% of Total Billed Charges,158.62,20,,126.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.62,20,,126.896,Percent of Total Billed Charges,20% of Total Billed Charges,158.62,20,,126.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,515.52,65,,412.416,Percent of Total Billed Charges,65% of Total Billed Charges,515.52,65,,412.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665,
COLON THRU STOMA,2260276,CDM,750,RC,44388,HCPCS,Outpatient,,,1500.71,750.36,,975.46,65,,780.368,Percent of Total Billed Charges,65% of Total Billed Charges,1020.48,68,,816.384,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,300.14,20,,240.112,Percent of Total Billed Charges,20% of Total Billed Charges,300.14,20,,240.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.14,20,,240.112,Percent of Total Billed Charges,20% of Total Billed Charges,300.14,20,,240.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975.46,65,,780.368,Percent of Total Billed Charges,65% of Total Billed Charges,975.46,65,,780.368,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1020.48,
RECOVERY ROOM 15MIN,2260280,CDM,710,RC,,,Outpatient,,,148.32,74.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.66,20,,23.728,Percent of Total Billed Charges,20% of Total Billed Charges,29.66,20,,23.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.66,20,,23.728,Percent of Total Billed Charges,20% of Total Billed Charges,29.66,20,,23.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.41,65,,77.128,Percent of Total Billed Charges,65% of Total Billed Charges,96.41,65,,77.128,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.66,96.41,
IV INFUSION/HYDRATION ADD 1 HR-OR,2260301,CDM,260,RC,96361,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,53.67,
IV INFUSION/MEDICATION ADD HR-OR,2260303,CDM,260,RC,96366,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
IM/SQ INJECTION-OR,2260306,CDM,260,RC,96372,HCPCS,Outpatient,,,49.44,24.72,,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,33.62,68,,26.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,53.67,
IV PUSH 15 MINUTES - OR,2260307,CDM,260,RC,96374,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
IV PUSH NEW/SEQ MED- OR,2260308,CDM,260,RC,96375,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
IV PUSH SAME MED 30 MIN-OR,2260309,CDM,260,RC,96376,HCPCS,Outpatient,,,67.98,33.99,,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,46.23,68,,36.984,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IV INF/MED 1ST HR,2260310,CDM,260,RC,96365,HCPCS,Outpatient,,,161.71,80.86,,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,109.96,68,,87.968,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,109.96,
IV INF/SEQ MED 1STHR,2260311,CDM,260,RC,96367,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
RESCUENET RETRIEVAL NET,2260312,CDM,272,RC,,,Outpatient,,,448.26,224.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.65,20,,71.72,Percent of Total Billed Charges,20% of Total Billed Charges,89.65,20,,71.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.65,20,,71.72,Percent of Total Billed Charges,20% of Total Billed Charges,89.65,20,,71.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.37,65,,233.096,Percent of Total Billed Charges,65% of Total Billed Charges,291.37,65,,233.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,291.37,
DEBRIDEMENT 1ST 20CM OR LESS,2260400,CDM,361,RC,97597,HCPCS,Outpatient,,,348.14,174.07,,226.29,65,,181.032,Percent of Total Billed Charges,65% of Total Billed Charges,236.74,68,,189.392,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.63,20,,55.704,Percent of Total Billed Charges,20% of Total Billed Charges,69.63,20,,55.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.63,20,,55.704,Percent of Total Billed Charges,20% of Total Billed Charges,69.63,20,,55.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.29,65,,181.032,Percent of Total Billed Charges,65% of Total Billed Charges,226.29,65,,181.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,236.74,
DEBRIDEMENT ADDITIONAL 20 CM,2260401,CDM,361,RC,97598,HCPCS,Outpatient,,,169.95,84.98,,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,115.57,68,,92.456,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,178,
DEBRIDEMENT-SUB 1ST 20CM OR LESS,2260402,CDM,361,RC,11042,HCPCS,Outpatient,,,721,360.50,,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,490.28,68,,392.224,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,490.28,
DEBRIDEMENT SUB ADD 20CM,2260403,CDM,510,RC,11045,HCPCS,Outpatient,,,978.5,489.25,,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,665.38,68,,532.304,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665.38,
DEBRIDEMENT MUSCLE FAS 20 CM,2260404,CDM,510,RC,11043,HCPCS,Outpatient,,,866.23,433.12,,563.05,65,,450.44,Percent of Total Billed Charges,65% of Total Billed Charges,589.04,68,,471.232,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,173.25,20,,138.6,Percent of Total Billed Charges,20% of Total Billed Charges,173.25,20,,138.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.25,20,,138.6,Percent of Total Billed Charges,20% of Total Billed Charges,173.25,20,,138.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.05,65,,450.44,Percent of Total Billed Charges,65% of Total Billed Charges,563.05,65,,450.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,589.04,
DEBRIDEMENT MUSCLE/FASCIA ADD 20CM,2260405,CDM,510,RC,11046,HCPCS,Outpatient,,,281.19,140.60,,182.77,65,,146.216,Percent of Total Billed Charges,65% of Total Billed Charges,191.21,68,,152.968,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,20,,44.992,Percent of Total Billed Charges,20% of Total Billed Charges,56.24,20,,44.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,20,,44.992,Percent of Total Billed Charges,20% of Total Billed Charges,56.24,20,,44.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.77,65,,146.216,Percent of Total Billed Charges,65% of Total Billed Charges,182.77,65,,146.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,191.21,
DEBRIDEMENT BONE MUSCLE/FASCIA 20 SQ CM,2260406,CDM,510,RC,11044,HCPCS,Outpatient,,,1442,721.00,,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,980.56,68,,784.448,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,980.56,
DEBRIDEMENT BONE EA ADD 20 SQ CM,2260407,CDM,510,RC,11047,HCPCS,Outpatient,,,470.71,235.36,,305.96,65,,244.768,Percent of Total Billed Charges,65% of Total Billed Charges,320.08,68,,256.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.14,20,,75.312,Percent of Total Billed Charges,20% of Total Billed Charges,94.14,20,,75.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.14,20,,75.312,Percent of Total Billed Charges,20% of Total Billed Charges,94.14,20,,75.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305.96,65,,244.768,Percent of Total Billed Charges,65% of Total Billed Charges,305.96,65,,244.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,320.08,
DEBRIDEMENT NAIL ANY METHOD 1-5,2260408,CDM,360,RC,11720,HCPCS,Outpatient,,,165.89,82.95,,107.83,65,,86.264,Percent of Total Billed Charges,65% of Total Billed Charges,112.81,68,,90.248,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.18,20,,26.544,Percent of Total Billed Charges,20% of Total Billed Charges,33.18,20,,26.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.18,20,,26.544,Percent of Total Billed Charges,20% of Total Billed Charges,33.18,20,,26.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.83,65,,86.264,Percent of Total Billed Charges,65% of Total Billed Charges,107.83,65,,86.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.18,178,
DEBRIDEMENT NAIL ANY METHOD 6 OR MORE,2260409,CDM,360,RC,11721,HCPCS,Outpatient,,,279.86,139.93,,181.91,65,,145.528,Percent of Total Billed Charges,65% of Total Billed Charges,190.3,68,,152.24,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.97,20,,44.776,Percent of Total Billed Charges,20% of Total Billed Charges,55.97,20,,44.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.97,20,,44.776,Percent of Total Billed Charges,20% of Total Billed Charges,55.97,20,,44.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.91,65,,145.528,Percent of Total Billed Charges,65% of Total Billed Charges,181.91,65,,145.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,190.3,
AVULSION NAIL PLATE PART/COMP SIMPLE 1,2260410,CDM,360,RC,11730,HCPCS,Outpatient,,,392.79,196.40,,255.31,65,,204.248,Percent of Total Billed Charges,65% of Total Billed Charges,267.1,68,,213.68,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.56,20,,62.848,Percent of Total Billed Charges,20% of Total Billed Charges,78.56,20,,62.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.56,20,,62.848,Percent of Total Billed Charges,20% of Total Billed Charges,78.56,20,,62.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.31,65,,204.248,Percent of Total Billed Charges,65% of Total Billed Charges,255.31,65,,204.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,267.1,
AVULSION NAIL PLATE PART/COMP SIMPLE ADD,2260411,CDM,360,RC,11732,HCPCS,Outpatient,,,123.6,61.80,,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,84.05,68,,67.24,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,178,
CHEMICAL CAUTERIZATION GRAN TISSUE,2260412,CDM,360,RC,17250,HCPCS,Outpatient,,,978.5,489.25,,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,665.38,68,,532.304,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665.38,
INS/DRAIN THROMBOSED HEMORRHOID,2260413,CDM,360,RC,46083,HCPCS,Outpatient,,,777.65,388.83,,505.47,65,,404.376,Percent of Total Billed Charges,65% of Total Billed Charges,528.8,68,,423.04,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.53,20,,124.424,Percent of Total Billed Charges,20% of Total Billed Charges,155.53,20,,124.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.53,20,,124.424,Percent of Total Billed Charges,20% of Total Billed Charges,155.53,20,,124.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,505.47,65,,404.376,Percent of Total Billed Charges,65% of Total Billed Charges,505.47,65,,404.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,528.8,
EGD PLACE GTUBE,2260414,CDM,360,RC,43246,HCPCS,Outpatient,,,2250.4,1125.20,,1462.76,65,,1170.208,Percent of Total Billed Charges,65% of Total Billed Charges,1530.27,68,,1224.216,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,450.08,20,,360.064,Percent of Total Billed Charges,20% of Total Billed Charges,450.08,20,,360.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450.08,20,,360.064,Percent of Total Billed Charges,20% of Total Billed Charges,450.08,20,,360.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1462.76,65,,1170.208,Percent of Total Billed Charges,65% of Total Billed Charges,1462.76,65,,1170.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1530.27,
EXC H-F-N-SP BENIGN + MARG >4CM,2260415,CDM,360,RC,11426,HCPCS,Outpatient,,,3310.35,1655.18,,2151.73,65,,1721.384,Percent of Total Billed Charges,65% of Total Billed Charges,2251.04,68,,1800.832,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,662.07,20,,529.656,Percent of Total Billed Charges,20% of Total Billed Charges,662.07,20,,529.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,662.07,20,,529.656,Percent of Total Billed Charges,20% of Total Billed Charges,662.07,20,,529.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2151.73,65,,1721.384,Percent of Total Billed Charges,65% of Total Billed Charges,2151.73,65,,1721.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2251.04,
EXC TR-EXT BENIGN+MARG >4.0CO,2260416,CDM,360,RC,11406,HCPCS,Outpatient,,,2028.55,1014.28,,1318.56,65,,1054.848,Percent of Total Billed Charges,65% of Total Billed Charges,1379.41,68,,1103.528,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,405.71,20,,324.568,Percent of Total Billed Charges,20% of Total Billed Charges,405.71,20,,324.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405.71,20,,324.568,Percent of Total Billed Charges,20% of Total Billed Charges,405.71,20,,324.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1318.56,65,,1054.848,Percent of Total Billed Charges,65% of Total Billed Charges,1318.56,65,,1054.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1379.41,
I & D OF VULVA OR PERINEAL ABSCESS,2260417,CDM,360,RC,56405,HCPCS,Outpatient,,,432.6,216.30,,281.19,65,,224.952,Percent of Total Billed Charges,65% of Total Billed Charges,294.17,68,,235.336,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,86.52,20,,69.216,Percent of Total Billed Charges,20% of Total Billed Charges,86.52,20,,69.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.52,20,,69.216,Percent of Total Billed Charges,20% of Total Billed Charges,86.52,20,,69.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.19,65,,224.952,Percent of Total Billed Charges,65% of Total Billed Charges,281.19,65,,224.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,419,
EXC TR-EXT BENIGN+MARG 3.1-4CM,2260418,CDM,361,RC,11404,HCPCS,Outpatient,,,553.11,276.56,,359.52,65,,287.616,Percent of Total Billed Charges,65% of Total Billed Charges,376.11,68,,300.888,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,110.62,20,,88.496,Percent of Total Billed Charges,20% of Total Billed Charges,110.62,20,,88.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.62,20,,88.496,Percent of Total Billed Charges,20% of Total Billed Charges,110.62,20,,88.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.52,65,,287.616,Percent of Total Billed Charges,65% of Total Billed Charges,359.52,65,,287.616,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665,
EXC TR-EXT BENIGN+MARG 1.1-2CM,2260419,CDM,361,RC,11402,HCPCS,Outpatient,,,576.8,288.40,,374.92,65,,299.936,Percent of Total Billed Charges,65% of Total Billed Charges,392.22,68,,313.776,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.36,20,,92.288,Percent of Total Billed Charges,20% of Total Billed Charges,115.36,20,,92.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.36,20,,92.288,Percent of Total Billed Charges,20% of Total Billed Charges,115.36,20,,92.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,374.92,65,,299.936,Percent of Total Billed Charges,65% of Total Billed Charges,374.92,65,,299.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,392.22,
I & D ABSCESS COMPLEX MULTIPLE,2260420,CDM,361,RC,10061,HCPCS,Outpatient,,,1555.3,777.65,,1010.95,65,,808.76,Percent of Total Billed Charges,65% of Total Billed Charges,1057.6,68,,846.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.06,20,,248.848,Percent of Total Billed Charges,20% of Total Billed Charges,311.06,20,,248.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.06,20,,248.848,Percent of Total Billed Charges,20% of Total Billed Charges,311.06,20,,248.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1010.95,65,,808.76,Percent of Total Billed Charges,65% of Total Billed Charges,1010.95,65,,808.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1057.6,
INTERNAL HRHC LIG W/O IMG,2260421,CDM,361,RC,46945,HCPCS,Outpatient,,,3379.95,1689.98,,2196.97,65,,1757.576,Percent of Total Billed Charges,65% of Total Billed Charges,2298.37,68,,1838.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675.99,20,,540.792,Percent of Total Billed Charges,20% of Total Billed Charges,675.99,20,,540.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675.99,20,,540.792,Percent of Total Billed Charges,20% of Total Billed Charges,675.99,20,,540.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2196.97,65,,1757.576,Percent of Total Billed Charges,65% of Total Billed Charges,2196.97,65,,1757.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2298.37,
EXC TR-EXT MLG MARG 1.1-2 CM,2260450,CDM,510,RC,11602,HCPCS,Outpatient,,,1442,721.00,,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,980.56,68,,784.448,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,980.56,
INJ. TENDON ORIGIN/INSERT,2260451,CDM,510,RC,20551,HCPCS,Outpatient,,,1442,721.00,,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,980.56,68,,784.448,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,288.4,20,,230.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,937.3,65,,749.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,980.56,
COLO POLYP REM SNARE,2261245,CDM,750,RC,45385,HCPCS,Outpatient,,,1558.39,779.20,,1012.95,65,,810.36,Percent of Total Billed Charges,65% of Total Billed Charges,1059.71,68,,847.768,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,311.68,20,,249.344,Percent of Total Billed Charges,20% of Total Billed Charges,311.68,20,,249.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.68,20,,249.344,Percent of Total Billed Charges,20% of Total Billed Charges,311.68,20,,249.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1012.95,65,,810.36,Percent of Total Billed Charges,65% of Total Billed Charges,1012.95,65,,810.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1059.71,
COLPOLYP REMW/HOT BI,2261271,CDM,750,RC,44392,HCPCS,Outpatient,,,1418.31,709.16,,921.9,65,,737.52,Percent of Total Billed Charges,65% of Total Billed Charges,964.45,68,,771.56,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,283.66,20,,226.928,Percent of Total Billed Charges,20% of Total Billed Charges,283.66,20,,226.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.66,20,,226.928,Percent of Total Billed Charges,20% of Total Billed Charges,283.66,20,,226.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,921.9,65,,737.52,Percent of Total Billed Charges,65% of Total Billed Charges,921.9,65,,737.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,964.45,
RECOVERY ROOM 30 MIN,2270001,CDM,710,RC,,,Outpatient,,,189.52,94.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.9,20,,30.32,Percent of Total Billed Charges,20% of Total Billed Charges,37.9,20,,30.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.9,20,,30.32,Percent of Total Billed Charges,20% of Total Billed Charges,37.9,20,,30.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.19,65,,98.552,Percent of Total Billed Charges,65% of Total Billed Charges,123.19,65,,98.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.9,123.19,
RECOVERY ROOM 60 MIN,2270003,CDM,710,RC,,,Outpatient,,,626.15,313.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.23,20,,100.184,Percent of Total Billed Charges,20% of Total Billed Charges,125.23,20,,100.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.23,20,,100.184,Percent of Total Billed Charges,20% of Total Billed Charges,125.23,20,,100.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,65,,325.6,Percent of Total Billed Charges,65% of Total Billed Charges,407,65,,325.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,407,
OVERNIGHT PULSE OXIMETRY,2270007,CDM,419,RC,94762,HCPCS,Outpatient,,,75,37.50,,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,93.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,93.57,
RECOVERY ROOM 15MIN,2270011,CDM,710,RC,,,Outpatient,,,116.39,58.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.28,20,,18.624,Percent of Total Billed Charges,20% of Total Billed Charges,23.28,20,,18.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.28,20,,18.624,Percent of Total Billed Charges,20% of Total Billed Charges,23.28,20,,18.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.65,65,,60.52,Percent of Total Billed Charges,65% of Total Billed Charges,75.65,65,,60.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.28,75.65,
ACC GPIV 20G,2500001,CDM,270,RC,,,Outpatient,,,286.67,143.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.33,20,,45.864,Percent of Total Billed Charges,20% of Total Billed Charges,57.33,20,,45.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.33,20,,45.864,Percent of Total Billed Charges,20% of Total Billed Charges,57.33,20,,45.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.34,65,,149.072,Percent of Total Billed Charges,65% of Total Billed Charges,186.34,65,,149.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,186.34,
POWERGLIDE RT BASIC 20G,2500002,CDM,270,RC,,,Outpatient,,,126.54,63.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.31,20,,20.248,Percent of Total Billed Charges,20% of Total Billed Charges,25.31,20,,20.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.31,20,,20.248,Percent of Total Billed Charges,20% of Total Billed Charges,25.31,20,,20.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.25,65,,65.8,Percent of Total Billed Charges,65% of Total Billed Charges,82.25,65,,65.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.31,82.25,
POWERGLIDE RT FULL 20G,2500003,CDM,270,RC,,,Outpatient,,,77.87,38.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,20,,12.456,Percent of Total Billed Charges,20% of Total Billed Charges,15.57,20,,12.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,20,,12.456,Percent of Total Billed Charges,20% of Total Billed Charges,15.57,20,,12.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.62,65,,40.496,Percent of Total Billed Charges,65% of Total Billed Charges,50.62,65,,40.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,53.67,
PROVENA MIDLINE 3FR SL,2500004,CDM,270,RC,,,Outpatient,,,267.38,133.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.48,20,,42.784,Percent of Total Billed Charges,20% of Total Billed Charges,53.48,20,,42.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.48,20,,42.784,Percent of Total Billed Charges,20% of Total Billed Charges,53.48,20,,42.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.8,65,,139.04,Percent of Total Billed Charges,65% of Total Billed Charges,173.8,65,,139.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.48,173.8,
POWERPICC 4FR SL,2500005,CDM,270,RC,,,Outpatient,,,396.75,198.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.35,20,,63.48,Percent of Total Billed Charges,20% of Total Billed Charges,79.35,20,,63.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.35,20,,63.48,Percent of Total Billed Charges,20% of Total Billed Charges,79.35,20,,63.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.89,65,,206.312,Percent of Total Billed Charges,65% of Total Billed Charges,257.89,65,,206.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,257.89,
NEEDLEGUIDE KIT 21G,2500006,CDM,270,RC,,,Outpatient,,,152.45,76.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.09,65,,79.272,Percent of Total Billed Charges,65% of Total Billed Charges,99.09,65,,79.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.49,99.09,
MICROEZ KIT 3.5FR,2500007,CDM,270,RC,,,Outpatient,,,35.69,17.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.14,20,,5.712,Percent of Total Billed Charges,20% of Total Billed Charges,7.14,20,,5.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.14,20,,5.712,Percent of Total Billed Charges,20% of Total Billed Charges,7.14,20,,5.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,65,,18.56,Percent of Total Billed Charges,65% of Total Billed Charges,23.2,65,,18.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.14,53.67,
MICROEZ KIT 4.5FR,2500008,CDM,270,RC,,,Outpatient,,,60.35,30.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.07,20,,9.656,Percent of Total Billed Charges,20% of Total Billed Charges,12.07,20,,9.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.07,20,,9.656,Percent of Total Billed Charges,20% of Total Billed Charges,12.07,20,,9.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.23,65,,31.384,Percent of Total Billed Charges,65% of Total Billed Charges,39.23,65,,31.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.07,53.67,
POWERPORT ISP 8FR,2500009,CDM,270,RC,,,Outpatient,,,659.72,329.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.94,20,,105.552,Percent of Total Billed Charges,20% of Total Billed Charges,131.94,20,,105.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.94,20,,105.552,Percent of Total Billed Charges,20% of Total Billed Charges,131.94,20,,105.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,428.82,65,,343.056,Percent of Total Billed Charges,65% of Total Billed Charges,428.82,65,,343.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,428.82,
RAPID RHINO EPISTAXIS,2520142,CDM,272,RC,,,Outpatient,,,291.9,145.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.38,20,,46.704,Percent of Total Billed Charges,20% of Total Billed Charges,58.38,20,,46.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.38,20,,46.704,Percent of Total Billed Charges,20% of Total Billed Charges,58.38,20,,46.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.74,65,,151.792,Percent of Total Billed Charges,65% of Total Billed Charges,189.74,65,,151.792,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,189.74,
COMBAT TOURNIQUET 6.5,2520184,CDM,271,RC,,,Outpatient,,,154.2,77.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.84,20,,24.672,Percent of Total Billed Charges,20% of Total Billed Charges,30.84,20,,24.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.84,20,,24.672,Percent of Total Billed Charges,20% of Total Billed Charges,30.84,20,,24.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.23,65,,80.184,Percent of Total Billed Charges,65% of Total Billed Charges,100.23,65,,80.184,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.84,100.23,
COMBAT TOURNIQUET 37.5,2520185,CDM,271,RC,,,Outpatient,,,154.2,77.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.84,20,,24.672,Percent of Total Billed Charges,20% of Total Billed Charges,30.84,20,,24.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.84,20,,24.672,Percent of Total Billed Charges,20% of Total Billed Charges,30.84,20,,24.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.23,65,,80.184,Percent of Total Billed Charges,65% of Total Billed Charges,100.23,65,,80.184,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.84,100.23,
IV-SOD CHL 9% 1000ML 2B1324X,2520283,CDM,636,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,35.72,68,,28.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,80,,33.616,Percent of Total Billed Charges,80% of Total Billed Charges,44.65,85,,35.72,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,44.65,
IV-SOD CHL 9% 500ML 2B1323Q,2520285,CDM,636,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,35.72,68,,28.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,80,,33.616,Percent of Total Billed Charges,80% of Total Billed Charges,44.65,85,,35.72,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,44.65,
IVSOD CHL 9% 250ML,2520289,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-DEX 5% 100ML (2B0087),2520292,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-DEX 5% 250ML 2B0062Q,2520293,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-DEX 5% & 1000ML (2B0064X),2520297,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-LACT RINGER 1000ML 2B2324X,2520301,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
ATOMIZER INTRANASAL MUCOSAL,2520307,CDM,271,RC,,,Outpatient,,,86.37,43.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,20,,13.816,Percent of Total Billed Charges,20% of Total Billed Charges,17.27,20,,13.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,20,,13.816,Percent of Total Billed Charges,20% of Total Billed Charges,17.27,20,,13.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.14,65,,44.912,Percent of Total Billed Charges,65% of Total Billed Charges,56.14,65,,44.912,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,56.14,
STETH0SCOPE/ DISPOSABLE,2520888,CDM,270,RC,,,Outpatient,,,63.09,31.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,20,,10.096,Percent of Total Billed Charges,20% of Total Billed Charges,12.62,20,,10.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,20,,10.096,Percent of Total Billed Charges,20% of Total Billed Charges,12.62,20,,10.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.01,65,,32.808,Percent of Total Billed Charges,65% of Total Billed Charges,41.01,65,,32.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,53.67,
IV-DEX 5% & SOD CHL .45% 1000ML,2521871,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-DEX 5% & SOD CHL .09% 1000ML 2B1064X,2521875,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-SOD.CHL .45% 1000ML 2B1314X,2521885,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-SOD.CHL9% 100 MINI+,2521921,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-SOD CHL 9% 50ML,2521922,CDM,636,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,35.72,68,,28.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,80,,33.616,Percent of Total Billed Charges,80% of Total Billed Charges,44.65,85,,35.72,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,44.65,
IV-SOD CHL 9% 100ML 2B1307,2521924,CDM,636,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,35.72,68,,28.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,80,,33.616,Percent of Total Billed Charges,80% of Total Billed Charges,44.65,85,,35.72,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,44.65,
PIGTAIL PNEUMO CATH KIT 10.2FR,2521985,CDM,272,RC,,,Outpatient,,,271.2,135.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.24,20,,43.392,Percent of Total Billed Charges,20% of Total Billed Charges,54.24,20,,43.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.24,20,,43.392,Percent of Total Billed Charges,20% of Total Billed Charges,54.24,20,,43.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.28,65,,141.024,Percent of Total Billed Charges,65% of Total Billed Charges,176.28,65,,141.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,176.28,
STOCKINETTE 4 IN X 25 YD,2530195,CDM,272,RC,,,Outpatient,,,65.71,32.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.71,65,,34.168,Percent of Total Billed Charges,65% of Total Billed Charges,42.71,65,,34.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,53.67,
SURGICEL 4X8,2530278,CDM,272,RC,,,Outpatient,,,1364.14,682.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.83,20,,218.264,Percent of Total Billed Charges,20% of Total Billed Charges,272.83,20,,218.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.83,20,,218.264,Percent of Total Billed Charges,20% of Total Billed Charges,272.83,20,,218.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,886.69,65,,709.352,Percent of Total Billed Charges,65% of Total Billed Charges,886.69,65,,709.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,886.69,
SURGICEL 0.5x2,2530279,CDM,272,RC,,,Outpatient,,,464.43,232.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.89,20,,74.312,Percent of Total Billed Charges,20% of Total Billed Charges,92.89,20,,74.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.89,20,,74.312,Percent of Total Billed Charges,20% of Total Billed Charges,92.89,20,,74.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.88,65,,241.504,Percent of Total Billed Charges,65% of Total Billed Charges,301.88,65,,241.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,301.88,
KANGAROO G-TUBE 18FR,2530527,CDM,272,RC,,,Outpatient,,,162.64,81.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.72,65,,84.576,Percent of Total Billed Charges,65% of Total Billed Charges,105.72,65,,84.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,105.72,
KANGAROO G-TUBE 22FR,2530528,CDM,272,RC,,,Outpatient,,,162.64,81.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.72,65,,84.576,Percent of Total Billed Charges,65% of Total Billed Charges,105.72,65,,84.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,105.72,
MIC G-TUBE 20FR,2530529,CDM,272,RC,,,Outpatient,,,196.98,98.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.04,65,,102.432,Percent of Total Billed Charges,65% of Total Billed Charges,128.04,65,,102.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,128.04,
MIC G-TUBE 18FR,2530530,CDM,272,RC,,,Outpatient,,,196.98,98.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.04,65,,102.432,Percent of Total Billed Charges,65% of Total Billed Charges,128.04,65,,102.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,128.04,
MIC G-TUBE 16FR,2530531,CDM,272,RC,,,Outpatient,,,196.98,98.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,39.4,20,,31.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.04,65,,102.432,Percent of Total Billed Charges,65% of Total Billed Charges,128.04,65,,102.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,128.04,
INFLATABLE RING CUSHION,2532033,CDM,271,RC,,,Outpatient,,,60.46,30.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,20,,9.672,Percent of Total Billed Charges,20% of Total Billed Charges,12.09,20,,9.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,20,,9.672,Percent of Total Billed Charges,20% of Total Billed Charges,12.09,20,,9.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.3,65,,31.44,Percent of Total Billed Charges,65% of Total Billed Charges,39.3,65,,31.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,53.67,
TRAY SUTURE/LACERATION,2532034,CDM,272,RC,,,Outpatient,,,65.71,32.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.71,65,,34.168,Percent of Total Billed Charges,65% of Total Billed Charges,42.71,65,,34.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,53.67,
MORGAN LENS,2532035,CDM,272,RC,,,Outpatient,,,104.08,52.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,20,,16.656,Percent of Total Billed Charges,20% of Total Billed Charges,20.82,20,,16.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,20,,16.656,Percent of Total Billed Charges,20% of Total Billed Charges,20.82,20,,16.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.65,65,,54.12,Percent of Total Billed Charges,65% of Total Billed Charges,67.65,65,,54.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,67.65,
INCISION & DRAINAGE KIT,2532036,CDM,272,RC,,,Outpatient,,,42.11,21.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.42,20,,6.736,Percent of Total Billed Charges,20% of Total Billed Charges,8.42,20,,6.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.42,20,,6.736,Percent of Total Billed Charges,20% of Total Billed Charges,8.42,20,,6.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.37,65,,21.896,Percent of Total Billed Charges,65% of Total Billed Charges,27.37,65,,21.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.42,53.67,
BANDAGE ELASTIC 2 IN,2532055,CDM,271,RC,,,Outpatient,,,7.42,3.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,65,,3.856,Percent of Total Billed Charges,65% of Total Billed Charges,4.82,65,,3.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,53.67,
BANDAGE ELASTIC 3 IN,2532057,CDM,271,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
BANDAGE ELASTIC 4 IN,2532059,CDM,271,RC,,,Outpatient,,,9.01,4.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.86,65,,4.688,Percent of Total Billed Charges,65% of Total Billed Charges,5.86,65,,4.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,53.67,
CORD CLAMP CLIPPER,2532060,CDM,272,RC,,,Outpatient,,,4.57,2.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,20,,0.728,Percent of Total Billed Charges,20% of Total Billed Charges,0.91,20,,0.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,20,,0.728,Percent of Total Billed Charges,20% of Total Billed Charges,0.91,20,,0.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,65,,2.376,Percent of Total Billed Charges,65% of Total Billed Charges,2.97,65,,2.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,53.67,
BANDAGE ELASTIC 6 IN,2532061,CDM,271,RC,,,Outpatient,,,15.4,7.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,65,,8.008,Percent of Total Billed Charges,65% of Total Billed Charges,10.01,65,,8.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,53.67,
DRESSING HYDROGEL AMORPHOUS 1oz,2532062,CDM,272,RC,,,Outpatient,,,20.7,10.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.14,20,,3.312,Percent of Total Billed Charges,20% of Total Billed Charges,4.14,20,,3.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.14,20,,3.312,Percent of Total Billed Charges,20% of Total Billed Charges,4.14,20,,3.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.46,65,,10.768,Percent of Total Billed Charges,65% of Total Billed Charges,13.46,65,,10.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.14,53.67,
SLING ARM MEDIUM,2532063,CDM,271,RC,,,Outpatient,,,34.97,17.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,20,,5.592,Percent of Total Billed Charges,20% of Total Billed Charges,6.99,20,,5.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,20,,5.592,Percent of Total Billed Charges,20% of Total Billed Charges,6.99,20,,5.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.73,65,,18.184,Percent of Total Billed Charges,65% of Total Billed Charges,22.73,65,,18.184,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,53.67,
UVC 3.5FR 15  CATHETER,2532064,CDM,272,RC,,,Outpatient,,,198.28,99.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.88,65,,103.104,Percent of Total Billed Charges,65% of Total Billed Charges,128.88,65,,103.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,128.88,
SLING ARM CHILD SM,2532067,CDM,271,RC,,,Outpatient,,,67.83,33.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.57,20,,10.856,Percent of Total Billed Charges,20% of Total Billed Charges,13.57,20,,10.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.57,20,,10.856,Percent of Total Billed Charges,20% of Total Billed Charges,13.57,20,,10.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.09,65,,35.272,Percent of Total Billed Charges,65% of Total Billed Charges,44.09,65,,35.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.57,53.67,
STOCKING ANTI-EMBOL  KNEE/SM,2532083,CDM,272,RC,,,Outpatient,,,41.61,20.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.05,65,,21.64,Percent of Total Billed Charges,65% of Total Billed Charges,27.05,65,,21.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,53.67,
CATHILON 20G- 1.88-IV,2532092,CDM,272,RC,,,Outpatient,,,18.7,9.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,20,,2.992,Percent of Total Billed Charges,20% of Total Billed Charges,3.74,20,,2.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,20,,2.992,Percent of Total Billed Charges,20% of Total Billed Charges,3.74,20,,2.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.16,65,,9.728,Percent of Total Billed Charges,65% of Total Billed Charges,12.16,65,,9.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,53.67,
RIB BELT FEMALE,2532093,CDM,271,RC,,,Outpatient,,,55.67,27.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.13,20,,8.904,Percent of Total Billed Charges,20% of Total Billed Charges,11.13,20,,8.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.13,20,,8.904,Percent of Total Billed Charges,20% of Total Billed Charges,11.13,20,,8.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.19,65,,28.952,Percent of Total Billed Charges,65% of Total Billed Charges,36.19,65,,28.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.13,53.67,
CAST PADDING 4X4,2532095,CDM,271,RC,,,Outpatient,,,32.96,16.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.59,20,,5.272,Percent of Total Billed Charges,20% of Total Billed Charges,6.59,20,,5.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.59,20,,5.272,Percent of Total Billed Charges,20% of Total Billed Charges,6.59,20,,5.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.42,65,,17.136,Percent of Total Billed Charges,65% of Total Billed Charges,21.42,65,,17.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.59,53.67,
CATH STRAIGHT (MALE) 14FR,2532096,CDM,272,RC,,,Outpatient,,,2.58,1.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,20,,0.416,Percent of Total Billed Charges,20% of Total Billed Charges,0.52,20,,0.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,20,,0.416,Percent of Total Billed Charges,20% of Total Billed Charges,0.52,20,,0.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,65,,1.344,Percent of Total Billed Charges,65% of Total Billed Charges,1.68,65,,1.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,53.67,
CATH MALE STRAIGHT 16FR COUDE,2532097,CDM,272,RC,,,Outpatient,,,11.23,5.62,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,20,,1.8,Percent of Total Billed Charges,20% of Total Billed Charges,2.25,20,,1.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,20,,1.8,Percent of Total Billed Charges,20% of Total Billed Charges,2.25,20,,1.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,65,,5.84,Percent of Total Billed Charges,65% of Total Billed Charges,7.3,65,,5.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,53.67,
MEDICO PASTE BANDAGE 3  (UNA BOOT),2532099,CDM,271,RC,,,Outpatient,,,54.44,27.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,20,,8.712,Percent of Total Billed Charges,20% of Total Billed Charges,10.89,20,,8.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,20,,8.712,Percent of Total Billed Charges,20% of Total Billed Charges,10.89,20,,8.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.39,65,,28.312,Percent of Total Billed Charges,65% of Total Billed Charges,35.39,65,,28.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,53.67,
CATHETER LEG STRAP,2532101,CDM,271,RC,,,Outpatient,,,34.35,17.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.87,20,,5.496,Percent of Total Billed Charges,20% of Total Billed Charges,6.87,20,,5.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.87,20,,5.496,Percent of Total Billed Charges,20% of Total Billed Charges,6.87,20,,5.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.33,65,,17.864,Percent of Total Billed Charges,65% of Total Billed Charges,22.33,65,,17.864,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.87,53.67,
URINE STRAINER,2532103,CDM,271,RC,,,Outpatient,,,7.88,3.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,20,,1.264,Percent of Total Billed Charges,20% of Total Billed Charges,1.58,20,,1.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,20,,1.264,Percent of Total Billed Charges,20% of Total Billed Charges,1.58,20,,1.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.12,65,,4.096,Percent of Total Billed Charges,65% of Total Billed Charges,5.12,65,,4.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,53.67,
CONNECTOR 5 IN 1,2532105,CDM,271,RC,,,Outpatient,,,9.58,4.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,20,,1.536,Percent of Total Billed Charges,20% of Total Billed Charges,1.92,20,,1.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,20,,1.536,Percent of Total Billed Charges,20% of Total Billed Charges,1.92,20,,1.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.23,65,,4.984,Percent of Total Billed Charges,65% of Total Billed Charges,6.23,65,,4.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,53.67,
RESTRAINT BODY VEST/ XL,2532106,CDM,271,RC,,,Outpatient,,,76.74,38.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.88,65,,39.904,Percent of Total Billed Charges,65% of Total Billed Charges,49.88,65,,39.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,53.67,
RESTRAINT BODY VEST/LRG,2532107,CDM,271,RC,,,Outpatient,,,107.64,53.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.53,20,,17.224,Percent of Total Billed Charges,20% of Total Billed Charges,21.53,20,,17.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.53,20,,17.224,Percent of Total Billed Charges,20% of Total Billed Charges,21.53,20,,17.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.97,65,,55.976,Percent of Total Billed Charges,65% of Total Billed Charges,69.97,65,,55.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.53,69.97,
RESTRAINT MITTEN CONTROL,2532108,CDM,271,RC,,,Outpatient,,,27,13.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,53.67,
RESTRAINT BODY VEST/MED,2532111,CDM,271,RC,,,Outpatient,,,105.06,52.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.01,20,,16.808,Percent of Total Billed Charges,20% of Total Billed Charges,21.01,20,,16.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.01,20,,16.808,Percent of Total Billed Charges,20% of Total Billed Charges,21.01,20,,16.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.29,65,,54.632,Percent of Total Billed Charges,65% of Total Billed Charges,68.29,65,,54.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.01,68.29,
TELEMETRY POUCH,2532117,CDM,271,RC,,,Outpatient,,,19.11,9.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.82,20,,3.056,Percent of Total Billed Charges,20% of Total Billed Charges,3.82,20,,3.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.82,20,,3.056,Percent of Total Billed Charges,20% of Total Billed Charges,3.82,20,,3.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.42,65,,9.936,Percent of Total Billed Charges,65% of Total Billed Charges,12.42,65,,9.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.82,53.67,
STOCKING ANTI-EMBOL  KNEE/XLG,2532121,CDM,272,RC,,,Outpatient,,,41.61,20.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.05,65,,21.64,Percent of Total Billed Charges,65% of Total Billed Charges,27.05,65,,21.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,53.67,
STOCKING ANTI-EMBOL  KNEE/MD,2532123,CDM,272,RC,,,Outpatient,,,41.61,20.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.05,65,,21.64,Percent of Total Billed Charges,65% of Total Billed Charges,27.05,65,,21.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,53.67,
STOCKING ANTI-EMBOL  KNEE/LG,2532125,CDM,272,RC,,,Outpatient,,,41.61,20.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,8.32,20,,6.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.05,65,,21.64,Percent of Total Billed Charges,65% of Total Billed Charges,27.05,65,,21.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,53.67,
STOCKING ANTI-EMBOL  THIGH/SM,2532127,CDM,272,RC,,,Outpatient,,,72.31,36.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,65,,37.6,Percent of Total Billed Charges,65% of Total Billed Charges,47,65,,37.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,53.67,
STOCKING ANTI-EMBOL  THIGH/LG,2532129,CDM,272,RC,,,Outpatient,,,72.31,36.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,65,,37.6,Percent of Total Billed Charges,65% of Total Billed Charges,47,65,,37.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,53.67,
STOCKING ANTI-EMBOL  THIGH/XL,2532130,CDM,270,RC,,,Outpatient,,,84.87,42.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.97,20,,13.576,Percent of Total Billed Charges,20% of Total Billed Charges,16.97,20,,13.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.97,20,,13.576,Percent of Total Billed Charges,20% of Total Billed Charges,16.97,20,,13.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.17,65,,44.136,Percent of Total Billed Charges,65% of Total Billed Charges,55.17,65,,44.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.97,55.17,
STOCKING  ANTI-EMBOL  THIGH/2XL,2532131,CDM,270,RC,,,Outpatient,,,85.84,42.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.17,20,,13.736,Percent of Total Billed Charges,20% of Total Billed Charges,17.17,20,,13.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.17,20,,13.736,Percent of Total Billed Charges,20% of Total Billed Charges,17.17,20,,13.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.8,65,,44.64,Percent of Total Billed Charges,65% of Total Billed Charges,55.8,65,,44.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.17,55.8,
RESTRAINT LIMB/WRIST,2532145,CDM,271,RC,,,Outpatient,,,74.62,37.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.92,20,,11.936,Percent of Total Billed Charges,20% of Total Billed Charges,14.92,20,,11.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.92,20,,11.936,Percent of Total Billed Charges,20% of Total Billed Charges,14.92,20,,11.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.5,65,,38.8,Percent of Total Billed Charges,65% of Total Billed Charges,48.5,65,,38.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.92,53.67,
URINE DRAINAGE BAG-LEG,2532149,CDM,272,RC,,,Outpatient,,,16.27,8.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,20,,2.6,Percent of Total Billed Charges,20% of Total Billed Charges,3.25,20,,2.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,20,,2.6,Percent of Total Billed Charges,20% of Total Billed Charges,3.25,20,,2.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.58,65,,8.464,Percent of Total Billed Charges,65% of Total Billed Charges,10.58,65,,8.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,53.67,
COMMODE COLL SYSTEM,2532155,CDM,271,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
SLING ARM LARGE,2532163,CDM,271,RC,,,Outpatient,,,21.84,10.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,20,,3.496,Percent of Total Billed Charges,20% of Total Billed Charges,4.37,20,,3.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,20,,3.496,Percent of Total Billed Charges,20% of Total Billed Charges,4.37,20,,3.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,65,,11.36,Percent of Total Billed Charges,65% of Total Billed Charges,14.2,65,,11.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,53.67,
SPLINT ALUMINUM FINGER 9X 3/4,2532173,CDM,271,RC,,,Outpatient,,,15.97,7.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.19,20,,2.552,Percent of Total Billed Charges,20% of Total Billed Charges,3.19,20,,2.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.19,20,,2.552,Percent of Total Billed Charges,20% of Total Billed Charges,3.19,20,,2.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.38,65,,8.304,Percent of Total Billed Charges,65% of Total Billed Charges,10.38,65,,8.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.19,53.67,
RIB BELT UNIVERSAL M/F,2532183,CDM,271,RC,,,Outpatient,,,55.67,27.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.13,20,,8.904,Percent of Total Billed Charges,20% of Total Billed Charges,11.13,20,,8.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.13,20,,8.904,Percent of Total Billed Charges,20% of Total Billed Charges,11.13,20,,8.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.19,65,,28.952,Percent of Total Billed Charges,65% of Total Billed Charges,36.19,65,,28.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.13,53.67,
STOCKING ANTI-EMBOL  THIGH/MD,2532185,CDM,272,RC,,,Outpatient,,,72.31,36.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,65,,37.6,Percent of Total Billed Charges,65% of Total Billed Charges,47,65,,37.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,53.67,
BOTTLE PERI/CLEANS 8OZ,2532189,CDM,271,RC,,,Outpatient,,,3.61,1.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,20,,0.576,Percent of Total Billed Charges,20% of Total Billed Charges,0.72,20,,0.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,20,,0.576,Percent of Total Billed Charges,20% of Total Billed Charges,0.72,20,,0.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.35,65,,1.88,Percent of Total Billed Charges,65% of Total Billed Charges,2.35,65,,1.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,53.67,
SHAVER TIP 4.0mm,2532190,CDM,271,RC,,,Outpatient,,,217.21,108.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.44,20,,34.752,Percent of Total Billed Charges,20% of Total Billed Charges,43.44,20,,34.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.44,20,,34.752,Percent of Total Billed Charges,20% of Total Billed Charges,43.44,20,,34.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.19,65,,112.952,Percent of Total Billed Charges,65% of Total Billed Charges,141.19,65,,112.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.44,141.19,
SHAVER BARREL FLUTED 5.0mm,2532191,CDM,271,RC,,,Outpatient,,,244.18,122.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.84,20,,39.072,Percent of Total Billed Charges,20% of Total Billed Charges,48.84,20,,39.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.84,20,,39.072,Percent of Total Billed Charges,20% of Total Billed Charges,48.84,20,,39.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.72,65,,126.976,Percent of Total Billed Charges,65% of Total Billed Charges,158.72,65,,126.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.84,158.72,
SHAVER ANGLED 4.0mm,2532192,CDM,271,RC,,,Outpatient,,,231.71,115.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.34,20,,37.072,Percent of Total Billed Charges,20% of Total Billed Charges,46.34,20,,37.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.34,20,,37.072,Percent of Total Billed Charges,20% of Total Billed Charges,46.34,20,,37.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.61,65,,120.488,Percent of Total Billed Charges,65% of Total Billed Charges,150.61,65,,120.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.34,150.61,
ELBOW PROTECTORS,2532193,CDM,271,RC,,,Outpatient,,,57.01,28.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.4,20,,9.12,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,20,,9.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.4,20,,9.12,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,20,,9.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.06,65,,29.648,Percent of Total Billed Charges,65% of Total Billed Charges,37.06,65,,29.648,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.4,53.67,
HEEL PROTECTORS,2532194,CDM,271,RC,,,Outpatient,,,75.3,37.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.06,20,,12.048,Percent of Total Billed Charges,20% of Total Billed Charges,15.06,20,,12.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.06,20,,12.048,Percent of Total Billed Charges,20% of Total Billed Charges,15.06,20,,12.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.95,65,,39.16,Percent of Total Billed Charges,65% of Total Billed Charges,48.95,65,,39.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.06,53.67,
ESMARK ST BANDAGE 4X9,2532195,CDM,271,RC,,,Outpatient,,,20.23,10.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,20,,3.24,Percent of Total Billed Charges,20% of Total Billed Charges,4.05,20,,3.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,20,,3.24,Percent of Total Billed Charges,20% of Total Billed Charges,4.05,20,,3.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.15,65,,10.52,Percent of Total Billed Charges,65% of Total Billed Charges,13.15,65,,10.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,53.67,
ESMARK ST BANDAGE 6X9,2532196,CDM,271,RC,,,Outpatient,,,36.5,18.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,20,,5.84,Percent of Total Billed Charges,20% of Total Billed Charges,7.3,20,,5.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,20,,5.84,Percent of Total Billed Charges,20% of Total Billed Charges,7.3,20,,5.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.73,65,,18.984,Percent of Total Billed Charges,65% of Total Billed Charges,23.73,65,,18.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,53.67,
4  STERILE COBAN,2532197,CDM,271,RC,,,Outpatient,,,34.19,17.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.84,20,,5.472,Percent of Total Billed Charges,20% of Total Billed Charges,6.84,20,,5.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.84,20,,5.472,Percent of Total Billed Charges,20% of Total Billed Charges,6.84,20,,5.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.22,65,,17.776,Percent of Total Billed Charges,65% of Total Billed Charges,22.22,65,,17.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.84,53.67,
SLING ARM SMALL,2532203,CDM,271,RC,,,Outpatient,,,19.52,9.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,20,,3.12,Percent of Total Billed Charges,20% of Total Billed Charges,3.9,20,,3.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,20,,3.12,Percent of Total Billed Charges,20% of Total Billed Charges,3.9,20,,3.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.69,65,,10.152,Percent of Total Billed Charges,65% of Total Billed Charges,12.69,65,,10.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,53.67,
BAG FLATUS,2532205,CDM,271,RC,,,Outpatient,,,13.24,6.62,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,20,,2.12,Percent of Total Billed Charges,20% of Total Billed Charges,2.65,20,,2.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,20,,2.12,Percent of Total Billed Charges,20% of Total Billed Charges,2.65,20,,2.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.61,65,,6.888,Percent of Total Billed Charges,65% of Total Billed Charges,8.61,65,,6.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,53.67,
BABY BOTTLE 8OZ,2532207,CDM,271,RC,,,Outpatient,,,7.52,3.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.89,65,,3.912,Percent of Total Billed Charges,65% of Total Billed Charges,4.89,65,,3.912,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,53.67,
IV ARM BOARD PED/INFANT,2532211,CDM,271,RC,,,Outpatient,,,25.34,12.67,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.07,20,,4.056,Percent of Total Billed Charges,20% of Total Billed Charges,5.07,20,,4.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.07,20,,4.056,Percent of Total Billed Charges,20% of Total Billed Charges,5.07,20,,4.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.47,65,,13.176,Percent of Total Billed Charges,65% of Total Billed Charges,16.47,65,,13.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.07,53.67,
SPLINT WST/FRM RIGHT-SM,2532243,CDM,271,RC,,,Outpatient,,,74.73,37.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.57,65,,38.856,Percent of Total Billed Charges,65% of Total Billed Charges,48.57,65,,38.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,53.67,
SPLiNT WST/FRM RIGHT-MD,2532245,CDM,271,RC,,,Outpatient,,,67.47,33.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.49,20,,10.792,Percent of Total Billed Charges,20% of Total Billed Charges,13.49,20,,10.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.49,20,,10.792,Percent of Total Billed Charges,20% of Total Billed Charges,13.49,20,,10.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.86,65,,35.088,Percent of Total Billed Charges,65% of Total Billed Charges,43.86,65,,35.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.49,53.67,
SPLINT WST/FRM RIGHT-LG,2532247,CDM,271,RC,,,Outpatient,,,74.73,37.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.57,65,,38.856,Percent of Total Billed Charges,65% of Total Billed Charges,48.57,65,,38.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,53.67,
SPLINT WST/FRM LEFT-SM,2532249,CDM,271,RC,,,Outpatient,,,74.73,37.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.57,65,,38.856,Percent of Total Billed Charges,65% of Total Billed Charges,48.57,65,,38.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,53.67,
SPLINT WST/FRM LEFT-MD,2532251,CDM,271,RC,S8451,HCPCS,Outpatient,,,67.47,33.74,,43.86,65,,35.088,Percent of Total Billed Charges,65% of Total Billed Charges,45.88,68,,36.704,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.49,20,,10.792,Percent of Total Billed Charges,20% of Total Billed Charges,13.49,20,,10.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.49,20,,10.792,Percent of Total Billed Charges,20% of Total Billed Charges,13.49,20,,10.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.86,65,,35.088,Percent of Total Billed Charges,65% of Total Billed Charges,43.86,65,,35.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.49,53.67,
SPLINT WST/FRM LEFT-LG,2532253,CDM,271,RC,,,Outpatient,,,74.73,37.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,14.95,20,,11.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.57,65,,38.856,Percent of Total Billed Charges,65% of Total Billed Charges,48.57,65,,38.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,53.67,
RHINO ROCKET STANDARD MD,2532276,CDM,272,RC,,,Outpatient,,,83.18,41.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.64,20,,13.312,Percent of Total Billed Charges,20% of Total Billed Charges,16.64,20,,13.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.64,20,,13.312,Percent of Total Billed Charges,20% of Total Billed Charges,16.64,20,,13.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.07,65,,43.256,Percent of Total Billed Charges,65% of Total Billed Charges,54.07,65,,43.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.64,54.07,
SURGICEL 1/2 X 2,2532277,CDM,272,RC,,,Outpatient,,,243.6,121.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.72,20,,38.976,Percent of Total Billed Charges,20% of Total Billed Charges,48.72,20,,38.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.72,20,,38.976,Percent of Total Billed Charges,20% of Total Billed Charges,48.72,20,,38.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.34,65,,126.672,Percent of Total Billed Charges,65% of Total Billed Charges,158.34,65,,126.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.72,158.34,
IMMOB SHOULDER MEDIUM,2532281,CDM,274,RC,L3675,HCPCS,Outpatient,,,53.82,26.91,,34.98,65,,27.984,Percent of Total Billed Charges,65% of Total Billed Charges,36.6,68,,29.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.76,20,,8.608,Percent of Total Billed Charges,20% of Total Billed Charges,10.76,20,,8.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.76,20,,8.608,Percent of Total Billed Charges,20% of Total Billed Charges,10.76,20,,8.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.06,80,,34.448,Percent of Total Billed Charges,80% of Total Billed Charges,45.75,85,,36.6,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.76,45.75,
IMMOB SHOULDER LARGE,2532283,CDM,274,RC,L3675,HCPCS,Outpatient,,,48.72,24.36,,31.67,65,,25.336,Percent of Total Billed Charges,65% of Total Billed Charges,33.13,68,,26.504,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.74,20,,7.792,Percent of Total Billed Charges,20% of Total Billed Charges,9.74,20,,7.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.74,20,,7.792,Percent of Total Billed Charges,20% of Total Billed Charges,9.74,20,,7.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.98,80,,31.184,Percent of Total Billed Charges,80% of Total Billed Charges,41.41,85,,33.128,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.74,41.41,
KNEE IMMOBOLIZER SMALL,2532287,CDM,274,RC,L1830,HCPCS,Outpatient,,,360.5,180.25,,234.33,65,,187.464,Percent of Total Billed Charges,65% of Total Billed Charges,245.14,68,,196.112,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.1,20,,57.68,Percent of Total Billed Charges,20% of Total Billed Charges,72.1,20,,57.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.1,20,,57.68,Percent of Total Billed Charges,20% of Total Billed Charges,72.1,20,,57.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.4,80,,230.72,Percent of Total Billed Charges,80% of Total Billed Charges,306.43,85,,245.144,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.1,306.43,
KNEE IMMOBOLIZER MED,2532289,CDM,274,RC,L1830,HCPCS,Outpatient,,,290.46,145.23,,188.8,65,,151.04,Percent of Total Billed Charges,65% of Total Billed Charges,197.51,68,,158.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.09,20,,46.472,Percent of Total Billed Charges,20% of Total Billed Charges,58.09,20,,46.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.09,20,,46.472,Percent of Total Billed Charges,20% of Total Billed Charges,58.09,20,,46.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.37,80,,185.896,Percent of Total Billed Charges,80% of Total Billed Charges,246.89,85,,197.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.09,246.89,
KNEE IMMOBOLIZER LARGE,2532290,CDM,274,RC,L1830,HCPCS,Outpatient,,,260.95,130.48,,169.62,65,,135.696,Percent of Total Billed Charges,65% of Total Billed Charges,177.45,68,,141.96,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.19,20,,41.752,Percent of Total Billed Charges,20% of Total Billed Charges,52.19,20,,41.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.19,20,,41.752,Percent of Total Billed Charges,20% of Total Billed Charges,52.19,20,,41.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.76,80,,167.008,Percent of Total Billed Charges,80% of Total Billed Charges,221.81,85,,177.448,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.19,221.81,
IMMOB SHOULDER SMALL,2532305,CDM,274,RC,L3675,HCPCS,Outpatient,,,28.84,14.42,,18.75,65,,15,Percent of Total Billed Charges,65% of Total Billed Charges,19.61,68,,15.688,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,80,,18.456,Percent of Total Billed Charges,80% of Total Billed Charges,24.51,85,,19.608,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,24.51,
ADAPTIC DRESSING 3X8,2532307,CDM,272,RC,,,Outpatient,,,10.45,5.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.09,20,,1.672,Percent of Total Billed Charges,20% of Total Billed Charges,2.09,20,,1.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.09,20,,1.672,Percent of Total Billed Charges,20% of Total Billed Charges,2.09,20,,1.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.79,65,,5.432,Percent of Total Billed Charges,65% of Total Billed Charges,6.79,65,,5.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.09,53.67,
ADAPTIC DRESSING 3x3,2532309,CDM,272,RC,,,Outpatient,,,4.27,2.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,20,,0.68,Percent of Total Billed Charges,20% of Total Billed Charges,0.85,20,,0.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,20,,0.68,Percent of Total Billed Charges,20% of Total Billed Charges,0.85,20,,0.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,65,,2.224,Percent of Total Billed Charges,65% of Total Billed Charges,2.78,65,,2.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,53.67,
VASELINE GAUZE 3x36,2532315,CDM,272,RC,,,Outpatient,,,7.16,3.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.43,20,,1.144,Percent of Total Billed Charges,20% of Total Billed Charges,1.43,20,,1.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.43,20,,1.144,Percent of Total Billed Charges,20% of Total Billed Charges,1.43,20,,1.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.65,65,,3.72,Percent of Total Billed Charges,65% of Total Billed Charges,4.65,65,,3.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.43,53.67,
TELFA DRESSING 4x8,2532321,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
SUTURE 1661G,2532325,CDM,272,RC,,,Outpatient,,,45.89,22.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.18,20,,7.344,Percent of Total Billed Charges,20% of Total Billed Charges,9.18,20,,7.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.18,20,,7.344,Percent of Total Billed Charges,20% of Total Billed Charges,9.18,20,,7.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.83,65,,23.864,Percent of Total Billed Charges,65% of Total Billed Charges,29.83,65,,23.864,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.18,53.67,
STATLOCK ADULT CATH,2532328,CDM,272,RC,,,Outpatient,,,26.37,13.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.14,65,,13.712,Percent of Total Billed Charges,65% of Total Billed Charges,17.14,65,,13.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,53.67,
SWABSTICK BENZOIN,2532333,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
TRAY TRACH CARE,2532341,CDM,272,RC,,,Outpatient,,,33.99,17.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,53.67,
SWABSTICK LEMON GLYCERIN,2532345,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
TUBE STOMACH 16FR,2532347,CDM,272,RC,,,Outpatient,,,15.4,7.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,65,,8.008,Percent of Total Billed Charges,65% of Total Billed Charges,10.01,65,,8.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,53.67,
SUTURE 662G,2532349,CDM,272,RC,,,Outpatient,,,38.16,19.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.63,20,,6.104,Percent of Total Billed Charges,20% of Total Billed Charges,7.63,20,,6.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.63,20,,6.104,Percent of Total Billed Charges,20% of Total Billed Charges,7.63,20,,6.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.8,65,,19.84,Percent of Total Billed Charges,65% of Total Billed Charges,24.8,65,,19.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.63,53.67,
SUTURE 1665G,2532353,CDM,272,RC,,,Outpatient,,,46.71,23.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.34,20,,7.472,Percent of Total Billed Charges,20% of Total Billed Charges,9.34,20,,7.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.34,20,,7.472,Percent of Total Billed Charges,20% of Total Billed Charges,9.34,20,,7.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.36,65,,24.288,Percent of Total Billed Charges,65% of Total Billed Charges,30.36,65,,24.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.34,53.67,
SUTURE J497G,2532354,CDM,272,RC,,,Outpatient,,,85.85,42.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.17,20,,13.736,Percent of Total Billed Charges,20% of Total Billed Charges,17.17,20,,13.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.17,20,,13.736,Percent of Total Billed Charges,20% of Total Billed Charges,17.17,20,,13.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.8,65,,44.64,Percent of Total Billed Charges,65% of Total Billed Charges,55.8,65,,44.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.17,55.8,
SUTURE J496G,2532355,CDM,272,RC,,,Outpatient,,,53.66,26.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.73,20,,8.584,Percent of Total Billed Charges,20% of Total Billed Charges,10.73,20,,8.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.73,20,,8.584,Percent of Total Billed Charges,20% of Total Billed Charges,10.73,20,,8.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.88,65,,27.904,Percent of Total Billed Charges,65% of Total Billed Charges,34.88,65,,27.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.73,53.67,
SUTURE H822H,2532356,CDM,272,RC,,,Outpatient,,,141.4,70.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.28,20,,22.624,Percent of Total Billed Charges,20% of Total Billed Charges,28.28,20,,22.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.28,20,,22.624,Percent of Total Billed Charges,20% of Total Billed Charges,28.28,20,,22.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.91,65,,73.528,Percent of Total Billed Charges,65% of Total Billed Charges,91.91,65,,73.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.28,91.91,
SUTURE 663G,2532369,CDM,272,RC,,,Outpatient,,,38.7,19.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.74,20,,6.192,Percent of Total Billed Charges,20% of Total Billed Charges,7.74,20,,6.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.74,20,,6.192,Percent of Total Billed Charges,20% of Total Billed Charges,7.74,20,,6.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,65,,20.128,Percent of Total Billed Charges,65% of Total Billed Charges,25.16,65,,20.128,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.74,53.67,
SWABSTICK BETADINE,2532375,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
SUCTION TUBING 6FT 1/4in,2532377,CDM,272,RC,,,Outpatient,,,5.41,2.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,20,,0.864,Percent of Total Billed Charges,20% of Total Billed Charges,1.08,20,,0.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,20,,0.864,Percent of Total Billed Charges,20% of Total Billed Charges,1.08,20,,0.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.52,65,,2.816,Percent of Total Billed Charges,65% of Total Billed Charges,3.52,65,,2.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,53.67,
SUCTION TUBING 10FT 1/4,2532378,CDM,271,RC,,,Outpatient,,,9.37,4.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.09,65,,4.872,Percent of Total Billed Charges,65% of Total Billed Charges,6.09,65,,4.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,53.67,
STERILE FIELD 18X26,2532383,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
SYRINGE BULB EAR/ULCER 2OZ,2532385,CDM,272,RC,,,Outpatient,,,7.36,3.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.47,20,,1.176,Percent of Total Billed Charges,20% of Total Billed Charges,1.47,20,,1.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.47,20,,1.176,Percent of Total Billed Charges,20% of Total Billed Charges,1.47,20,,1.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,65,,3.824,Percent of Total Billed Charges,65% of Total Billed Charges,4.78,65,,3.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.47,53.67,
ABD PAD 8X10,2532387,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
URINE DRAINAGE BAG,2532389,CDM,272,RC,,,Outpatient,,,55.57,27.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.11,20,,8.888,Percent of Total Billed Charges,20% of Total Billed Charges,11.11,20,,8.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.11,20,,8.888,Percent of Total Billed Charges,20% of Total Billed Charges,11.11,20,,8.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.12,65,,28.896,Percent of Total Billed Charges,65% of Total Billed Charges,36.12,65,,28.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.11,53.67,
NG-NI FEED TUBE 8FR,2532390,CDM,272,RC,,,Outpatient,,,191.25,95.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.25,20,,30.6,Percent of Total Billed Charges,20% of Total Billed Charges,38.25,20,,30.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.25,20,,30.6,Percent of Total Billed Charges,20% of Total Billed Charges,38.25,20,,30.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.31,65,,99.448,Percent of Total Billed Charges,65% of Total Billed Charges,124.31,65,,99.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.25,124.31,
TUBE STOMACH 12FR,2532391,CDM,272,RC,,,Outpatient,,,12.57,6.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.51,20,,2.008,Percent of Total Billed Charges,20% of Total Billed Charges,2.51,20,,2.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.51,20,,2.008,Percent of Total Billed Charges,20% of Total Billed Charges,2.51,20,,2.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.17,65,,6.536,Percent of Total Billed Charges,65% of Total Billed Charges,8.17,65,,6.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.51,53.67,
URINE COLLECTOR- PEDIATRIC,2532393,CDM,272,RC,,,Outpatient,,,8.55,4.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,20,,1.368,Percent of Total Billed Charges,20% of Total Billed Charges,1.71,20,,1.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,20,,1.368,Percent of Total Billed Charges,20% of Total Billed Charges,1.71,20,,1.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,65,,4.448,Percent of Total Billed Charges,65% of Total Billed Charges,5.56,65,,4.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,53.67,
STERI STRIP 1/4X3,2532395,CDM,272,RC,,,Outpatient,,,8.09,4.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,20,,1.296,Percent of Total Billed Charges,20% of Total Billed Charges,1.62,20,,1.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,20,,1.296,Percent of Total Billed Charges,20% of Total Billed Charges,1.62,20,,1.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.26,65,,4.208,Percent of Total Billed Charges,65% of Total Billed Charges,5.26,65,,4.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,53.67,
STERI STRIP 1/2X4,2532396,CDM,272,RC,,,Outpatient,,,10.94,5.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,20,,1.752,Percent of Total Billed Charges,20% of Total Billed Charges,2.19,20,,1.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,20,,1.752,Percent of Total Billed Charges,20% of Total Billed Charges,2.19,20,,1.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.11,65,,5.688,Percent of Total Billed Charges,65% of Total Billed Charges,7.11,65,,5.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,53.67,
TELFA DRESSING 4x3,2532397,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
TONGUE BLADE STERILE,2532399,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
GAUZE PAD 4X4 12 PL/10 PK,2532401,CDM,272,RC,,,Outpatient,,,6.8,3.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,53.67,
DRESSING WET STR 8X4,2532403,CDM,272,RC,,,Outpatient,,,12.26,6.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,20,,1.96,Percent of Total Billed Charges,20% of Total Billed Charges,2.45,20,,1.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,20,,1.96,Percent of Total Billed Charges,20% of Total Billed Charges,2.45,20,,1.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.97,65,,6.376,Percent of Total Billed Charges,65% of Total Billed Charges,7.97,65,,6.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,53.67,
EYE PAD OVAL/STERILE,2532405,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
GAUZE SPONGE 2X2 STERILE,2532411,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
VASELINE GAUZE 3x18,2532413,CDM,272,RC,,,Outpatient,,,6.49,3.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,53.67,
GAUZE PAD 4X4 GEN-USE,2532415,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
CHEST DRAINGE UNIT PLEUR-EVAC,2532417,CDM,272,RC,,,Outpatient,,,348.19,174.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.64,20,,55.712,Percent of Total Billed Charges,20% of Total Billed Charges,69.64,20,,55.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.64,20,,55.712,Percent of Total Billed Charges,20% of Total Billed Charges,69.64,20,,55.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.32,65,,181.056,Percent of Total Billed Charges,65% of Total Billed Charges,226.32,65,,181.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,226.32,
CHEST DRAINAGE UNIT THORA-SEAL III,2532418,CDM,272,RC,32556,HCPCS,Outpatient,,,261.72,130.86,,170.12,65,,136.096,Percent of Total Billed Charges,65% of Total Billed Charges,177.97,68,,142.376,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.34,20,,41.872,Percent of Total Billed Charges,20% of Total Billed Charges,52.34,20,,41.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.34,20,,41.872,Percent of Total Billed Charges,20% of Total Billed Charges,52.34,20,,41.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.12,65,,136.096,Percent of Total Billed Charges,65% of Total Billed Charges,170.12,65,,136.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.34,665,
SKIN STAPLER REGULAR DISP,2532420,CDM,272,RC,,,Outpatient,,,41.3,20.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.26,20,,6.608,Percent of Total Billed Charges,20% of Total Billed Charges,8.26,20,,6.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.26,20,,6.608,Percent of Total Billed Charges,20% of Total Billed Charges,8.26,20,,6.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.85,65,,21.48,Percent of Total Billed Charges,65% of Total Billed Charges,26.85,65,,21.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.26,53.67,
CATH FOLEY TRAY 16FR,2532421,CDM,272,RC,,,Outpatient,,,74.98,37.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.74,65,,38.992,Percent of Total Billed Charges,65% of Total Billed Charges,48.74,65,,38.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,53.67,
CUP SPECIMEN 4OZ STERILE,2532423,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
CATHILON 14G - IV,2532433,CDM,272,RC,,,Outpatient,,,17.15,8.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.43,20,,2.744,Percent of Total Billed Charges,20% of Total Billed Charges,3.43,20,,2.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.43,20,,2.744,Percent of Total Billed Charges,20% of Total Billed Charges,3.43,20,,2.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.15,65,,8.92,Percent of Total Billed Charges,65% of Total Billed Charges,11.15,65,,8.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.43,53.67,
CATHILON 20G - IV,2532437,CDM,272,RC,,,Outpatient,,,17.25,8.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.21,65,,8.968,Percent of Total Billed Charges,65% of Total Billed Charges,11.21,65,,8.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,53.67,
CATHILON 22G - IV,2532439,CDM,272,RC,,,Outpatient,,,17.25,8.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.21,65,,8.968,Percent of Total Billed Charges,65% of Total Billed Charges,11.21,65,,8.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,53.67,
ENTERNAL FEED PUMP BAG SET 1000ML W/ FLU,2532440,CDM,271,RC,,,Outpatient,,,47.45,23.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.49,20,,7.592,Percent of Total Billed Charges,20% of Total Billed Charges,9.49,20,,7.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.49,20,,7.592,Percent of Total Billed Charges,20% of Total Billed Charges,9.49,20,,7.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.84,65,,24.672,Percent of Total Billed Charges,65% of Total Billed Charges,30.84,65,,24.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.49,53.67,
CATHILON 18G - IV,2532441,CDM,272,RC,,,Outpatient,,,17.25,8.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.21,65,,8.968,Percent of Total Billed Charges,65% of Total Billed Charges,11.21,65,,8.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,53.67,
KLING BANDAGE 2IN STERILE,2532443,CDM,272,RC,,,Outpatient,,,3.81,1.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,20,,0.608,Percent of Total Billed Charges,20% of Total Billed Charges,0.76,20,,0.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,20,,0.608,Percent of Total Billed Charges,20% of Total Billed Charges,0.76,20,,0.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.48,65,,1.984,Percent of Total Billed Charges,65% of Total Billed Charges,2.48,65,,1.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,53.67,
SUTURE 661G,2532445,CDM,272,RC,,,Outpatient,,,22.61,11.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,20,,3.616,Percent of Total Billed Charges,20% of Total Billed Charges,4.52,20,,3.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,20,,3.616,Percent of Total Billed Charges,20% of Total Billed Charges,4.52,20,,3.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,65,,11.76,Percent of Total Billed Charges,65% of Total Billed Charges,14.7,65,,11.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,53.67,
CATHILON 24G - IV,2532447,CDM,272,RC,,,Outpatient,,,17.25,8.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,3.45,20,,2.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.21,65,,8.968,Percent of Total Billed Charges,65% of Total Billed Charges,11.21,65,,8.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,53.67,
CENTRAL LINE PLACEMENT KIT,2532448,CDM,272,RC,,,Outpatient,,,193.18,96.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.64,20,,30.912,Percent of Total Billed Charges,20% of Total Billed Charges,38.64,20,,30.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.64,20,,30.912,Percent of Total Billed Charges,20% of Total Billed Charges,38.64,20,,30.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.57,65,,100.456,Percent of Total Billed Charges,65% of Total Billed Charges,125.57,65,,100.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.64,125.57,
KANGAROO EPUMP BAG W/SPIKE,2532449,CDM,272,RC,,,Outpatient,,,48.26,24.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.65,20,,7.72,Percent of Total Billed Charges,20% of Total Billed Charges,9.65,20,,7.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.65,20,,7.72,Percent of Total Billed Charges,20% of Total Billed Charges,9.65,20,,7.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.37,65,,25.096,Percent of Total Billed Charges,65% of Total Billed Charges,31.37,65,,25.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.65,53.67,
CAUTERY 1/2 W/ FINE TIP,2532450,CDM,272,RC,,,Outpatient,,,102.08,51.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.42,20,,16.336,Percent of Total Billed Charges,20% of Total Billed Charges,20.42,20,,16.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.42,20,,16.336,Percent of Total Billed Charges,20% of Total Billed Charges,20.42,20,,16.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.35,65,,53.08,Percent of Total Billed Charges,65% of Total Billed Charges,66.35,65,,53.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.42,66.35,
GLOVE SURGEON  7,2532453,CDM,272,RC,,,Outpatient,,,9.79,4.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,20,,1.568,Percent of Total Billed Charges,20% of Total Billed Charges,1.96,20,,1.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,20,,1.568,Percent of Total Billed Charges,20% of Total Billed Charges,1.96,20,,1.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.36,65,,5.088,Percent of Total Billed Charges,65% of Total Billed Charges,6.36,65,,5.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,53.67,
GLOVE SURGEON  8.5,2532454,CDM,272,RC,,,Outpatient,,,9.79,4.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,20,,1.568,Percent of Total Billed Charges,20% of Total Billed Charges,1.96,20,,1.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,20,,1.568,Percent of Total Billed Charges,20% of Total Billed Charges,1.96,20,,1.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.36,65,,5.088,Percent of Total Billed Charges,65% of Total Billed Charges,6.36,65,,5.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,53.67,
GLOVE SURGEON  7.5,2532455,CDM,272,RC,,,Outpatient,,,9.75,4.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.34,65,,5.072,Percent of Total Billed Charges,65% of Total Billed Charges,6.34,65,,5.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,53.67,
GLOVE SURGEON  6.5,2532457,CDM,272,RC,,,Outpatient,,,9.75,4.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.34,65,,5.072,Percent of Total Billed Charges,65% of Total Billed Charges,6.34,65,,5.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,53.67,
TRAY THORACENTISIS,2532465,CDM,272,RC,,,Outpatient,,,198.28,99.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.88,65,,103.104,Percent of Total Billed Charges,65% of Total Billed Charges,128.88,65,,103.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,128.88,
VASELINE GAUZE 1x8,2532469,CDM,272,RC,,,Outpatient,,,10.25,5.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,20,,1.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.05,20,,1.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,20,,1.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.05,20,,1.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.66,65,,5.328,Percent of Total Billed Charges,65% of Total Billed Charges,6.66,65,,5.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,53.67,
KLING BANDAGE 3IN STERILE,2532471,CDM,272,RC,,,Outpatient,,,7.83,3.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,20,,1.256,Percent of Total Billed Charges,20% of Total Billed Charges,1.57,20,,1.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,20,,1.256,Percent of Total Billed Charges,20% of Total Billed Charges,1.57,20,,1.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.09,65,,4.072,Percent of Total Billed Charges,65% of Total Billed Charges,5.09,65,,4.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,53.67,
BANDAID 2 x4.5,2532473,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
SUTURE 1662G,2532477,CDM,272,RC,,,Outpatient,,,63.04,31.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.61,20,,10.088,Percent of Total Billed Charges,20% of Total Billed Charges,12.61,20,,10.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.61,20,,10.088,Percent of Total Billed Charges,20% of Total Billed Charges,12.61,20,,10.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.98,65,,32.784,Percent of Total Billed Charges,65% of Total Billed Charges,40.98,65,,32.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.61,53.67,
APPLICATORS COTTON TIP-STERILE,2532479,CDM,272,RC,,,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,2.21,65,,1.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,53.67,
CATH DRAIN PLUG W/CAP,2532485,CDM,272,RC,,,Outpatient,,,5.41,2.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,20,,0.864,Percent of Total Billed Charges,20% of Total Billed Charges,1.08,20,,0.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,20,,0.864,Percent of Total Billed Charges,20% of Total Billed Charges,1.08,20,,0.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.52,65,,2.816,Percent of Total Billed Charges,65% of Total Billed Charges,3.52,65,,2.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,53.67,
CATHETER SUCTION KIT 8FR,2532487,CDM,272,RC,,,Outpatient,,,6.75,3.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,20,,1.08,Percent of Total Billed Charges,20% of Total Billed Charges,1.35,20,,1.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,20,,1.08,Percent of Total Billed Charges,20% of Total Billed Charges,1.35,20,,1.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.39,65,,3.512,Percent of Total Billed Charges,65% of Total Billed Charges,4.39,65,,3.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,53.67,
SUCTION CATHETER 14FR,2532488,CDM,272,RC,,,Outpatient,,,0.36,0.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,20,,0.056,Percent of Total Billed Charges,20% of Total Billed Charges,0.07,20,,0.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,20,,0.056,Percent of Total Billed Charges,20% of Total Billed Charges,0.07,20,,0.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,65,,0.184,Percent of Total Billed Charges,65% of Total Billed Charges,0.23,65,,0.184,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,53.67,
TUBE STOMACH 14FR,2532491,CDM,272,RC,,,Outpatient,,,15.4,7.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,3.08,20,,2.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,65,,8.008,Percent of Total Billed Charges,65% of Total Billed Charges,10.01,65,,8.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,53.67,
TUBE STOMACH 18FR SALEM SUMP,2532493,CDM,272,RC,,,Outpatient,,,11.69,5.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,20,,1.872,Percent of Total Billed Charges,20% of Total Billed Charges,2.34,20,,1.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,20,,1.872,Percent of Total Billed Charges,20% of Total Billed Charges,2.34,20,,1.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,65,,6.08,Percent of Total Billed Charges,65% of Total Billed Charges,7.6,65,,6.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,53.67,
CATH FOLEY TRAY 18FR,2532495,CDM,272,RC,,,Outpatient,,,91.36,45.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.27,20,,14.616,Percent of Total Billed Charges,20% of Total Billed Charges,18.27,20,,14.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.27,20,,14.616,Percent of Total Billed Charges,20% of Total Billed Charges,18.27,20,,14.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.38,65,,47.504,Percent of Total Billed Charges,65% of Total Billed Charges,59.38,65,,47.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.27,59.38,
ENEMA SET ECONOMY,2532501,CDM,272,RC,,,Outpatient,,,57.27,28.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.45,20,,9.16,Percent of Total Billed Charges,20% of Total Billed Charges,11.45,20,,9.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.45,20,,9.16,Percent of Total Billed Charges,20% of Total Billed Charges,11.45,20,,9.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.23,65,,29.784,Percent of Total Billed Charges,65% of Total Billed Charges,37.23,65,,29.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.45,53.67,
KERLEX BANDAGE 4IN,2532503,CDM,272,RC,,,Outpatient,,,11.79,5.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,20,,1.888,Percent of Total Billed Charges,20% of Total Billed Charges,2.36,20,,1.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,20,,1.888,Percent of Total Billed Charges,20% of Total Billed Charges,2.36,20,,1.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.66,65,,6.128,Percent of Total Billed Charges,65% of Total Billed Charges,7.66,65,,6.128,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,53.67,
TRAY SUTURE REMOVAL/DISP,2532505,CDM,272,RC,,,Outpatient,,,12.57,6.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.51,20,,2.008,Percent of Total Billed Charges,20% of Total Billed Charges,2.51,20,,2.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.51,20,,2.008,Percent of Total Billed Charges,20% of Total Billed Charges,2.51,20,,2.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.17,65,,6.536,Percent of Total Billed Charges,65% of Total Billed Charges,8.17,65,,6.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.51,53.67,
SKIN STAPLER PRECISE DISP,2532509,CDM,272,RC,,,Outpatient,,,68.19,34.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.64,20,,10.912,Percent of Total Billed Charges,20% of Total Billed Charges,13.64,20,,10.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.64,20,,10.912,Percent of Total Billed Charges,20% of Total Billed Charges,13.64,20,,10.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.32,65,,35.456,Percent of Total Billed Charges,65% of Total Billed Charges,44.32,65,,35.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.64,53.67,
STAPLE EXTRACTOR,2532513,CDM,272,RC,,,Outpatient,,,50.32,25.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.06,20,,8.048,Percent of Total Billed Charges,20% of Total Billed Charges,10.06,20,,8.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.06,20,,8.048,Percent of Total Billed Charges,20% of Total Billed Charges,10.06,20,,8.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.71,65,,26.168,Percent of Total Billed Charges,65% of Total Billed Charges,32.71,65,,26.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.06,53.67,
YANKAUER SUCTION TIP K87,2532515,CDM,272,RC,,,Outpatient,,,20.5,10.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.1,20,,3.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.1,20,,3.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.1,20,,3.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.1,20,,3.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.33,65,,10.664,Percent of Total Billed Charges,65% of Total Billed Charges,13.33,65,,10.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.1,53.67,
IV SET NITRO,2532519,CDM,272,RC,,,Outpatient,,,70.09,35.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.02,20,,11.216,Percent of Total Billed Charges,20% of Total Billed Charges,14.02,20,,11.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.02,20,,11.216,Percent of Total Billed Charges,20% of Total Billed Charges,14.02,20,,11.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.56,65,,36.448,Percent of Total Billed Charges,65% of Total Billed Charges,45.56,65,,36.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.02,53.67,
SUTURE 8682G,2532521,CDM,272,RC,,,Outpatient,,,78.07,39.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.61,20,,12.488,Percent of Total Billed Charges,20% of Total Billed Charges,15.61,20,,12.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.61,20,,12.488,Percent of Total Billed Charges,20% of Total Billed Charges,15.61,20,,12.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.75,65,,40.6,Percent of Total Billed Charges,65% of Total Billed Charges,50.75,65,,40.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.61,53.67,
SUTURE 8697G,2532523,CDM,272,RC,,,Outpatient,,,66.23,33.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,20,,10.6,Percent of Total Billed Charges,20% of Total Billed Charges,13.25,20,,10.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,20,,10.6,Percent of Total Billed Charges,20% of Total Billed Charges,13.25,20,,10.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.05,65,,34.44,Percent of Total Billed Charges,65% of Total Billed Charges,43.05,65,,34.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,53.67,
SUTURE 8698G,2532525,CDM,272,RC,,,Outpatient,,,57.17,28.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.43,20,,9.144,Percent of Total Billed Charges,20% of Total Billed Charges,11.43,20,,9.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.43,20,,9.144,Percent of Total Billed Charges,20% of Total Billed Charges,11.43,20,,9.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.16,65,,29.728,Percent of Total Billed Charges,65% of Total Billed Charges,37.16,65,,29.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.43,53.67,
KANGAROO G-TUBE 16FR,2532527,CDM,272,RC,,,Outpatient,,,117.47,58.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.49,20,,18.792,Percent of Total Billed Charges,20% of Total Billed Charges,23.49,20,,18.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.49,20,,18.792,Percent of Total Billed Charges,20% of Total Billed Charges,23.49,20,,18.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.36,65,,61.088,Percent of Total Billed Charges,65% of Total Billed Charges,76.36,65,,61.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.49,76.36,
KANGAROO G-TUBE 20FR,2532529,CDM,272,RC,,,Outpatient,,,162.64,81.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.72,65,,84.576,Percent of Total Billed Charges,65% of Total Billed Charges,105.72,65,,84.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,105.72,
TUBE GASTROSTOMY 22FR,2532530,CDM,272,RC,,,Outpatient,,,93.78,46.89,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.76,20,,15.008,Percent of Total Billed Charges,20% of Total Billed Charges,18.76,20,,15.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.76,20,,15.008,Percent of Total Billed Charges,20% of Total Billed Charges,18.76,20,,15.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.96,65,,48.768,Percent of Total Billed Charges,65% of Total Billed Charges,60.96,65,,48.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.76,60.96,
ADAPTIC DRESSING 3X8 3PACK,2532531,CDM,272,RC,,,Outpatient,,,16.74,8.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,20,,2.68,Percent of Total Billed Charges,20% of Total Billed Charges,3.35,20,,2.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,20,,2.68,Percent of Total Billed Charges,20% of Total Billed Charges,3.35,20,,2.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.88,65,,8.704,Percent of Total Billed Charges,65% of Total Billed Charges,10.88,65,,8.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,53.67,
KANGAROO G-TUBE 14FR,2532532,CDM,272,RC,,,Outpatient,,,162.64,81.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,32.53,20,,26.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.72,65,,84.576,Percent of Total Billed Charges,65% of Total Billed Charges,105.72,65,,84.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,105.72,
CATH FOLEY 30FR 30CC,2532537,CDM,272,RC,,,Outpatient,,,41.05,20.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.21,20,,6.568,Percent of Total Billed Charges,20% of Total Billed Charges,8.21,20,,6.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.21,20,,6.568,Percent of Total Billed Charges,20% of Total Billed Charges,8.21,20,,6.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.68,65,,21.344,Percent of Total Billed Charges,65% of Total Billed Charges,26.68,65,,21.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.21,53.67,
GLOVE SURGEON 8,2532545,CDM,272,RC,,,Outpatient,,,9.75,4.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.34,65,,5.072,Percent of Total Billed Charges,65% of Total Billed Charges,6.34,65,,5.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,53.67,
PORT-A-CATH GRIPPER 20GX1,2532547,CDM,272,RC,,,Outpatient,,,54.64,27.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.93,20,,8.744,Percent of Total Billed Charges,20% of Total Billed Charges,10.93,20,,8.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.93,20,,8.744,Percent of Total Billed Charges,20% of Total Billed Charges,10.93,20,,8.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.52,65,,28.416,Percent of Total Billed Charges,65% of Total Billed Charges,35.52,65,,28.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.93,53.67,
IRRIGATION SOD CHL. 9% 3000ML,2532568,CDM,272,RC,,,Outpatient,,,45.22,22.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.04,20,,7.232,Percent of Total Billed Charges,20% of Total Billed Charges,9.04,20,,7.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.04,20,,7.232,Percent of Total Billed Charges,20% of Total Billed Charges,9.04,20,,7.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.39,65,,23.512,Percent of Total Billed Charges,65% of Total Billed Charges,29.39,65,,23.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.04,53.67,
IV PRIMARY SET (2C8571),2532571,CDM,272,RC,,,Outpatient,,,36,18.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,53.67,
IV SECONDARY SET (2C7461),2532573,CDM,272,RC,,,Outpatient,,,8.7,4.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.66,65,,4.528,Percent of Total Billed Charges,65% of Total Billed Charges,5.66,65,,4.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,53.67,
IV SET DUO-VENT SPIKE,2532575,CDM,272,RC,,,Outpatient,,,17.36,8.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,65,,9.024,Percent of Total Billed Charges,65% of Total Billed Charges,11.28,65,,9.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,53.67,
IV EXT W INJ SITE,2532577,CDM,272,RC,,,Outpatient,,,43.67,21.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,20,,6.984,Percent of Total Billed Charges,20% of Total Billed Charges,8.73,20,,6.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,20,,6.984,Percent of Total Billed Charges,20% of Total Billed Charges,8.73,20,,6.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.39,65,,22.712,Percent of Total Billed Charges,65% of Total Billed Charges,28.39,65,,22.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,53.67,
IV BLOOD ADMIN SET (2C8751),2532581,CDM,272,RC,,,Outpatient,,,21.84,10.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,20,,3.496,Percent of Total Billed Charges,20% of Total Billed Charges,4.37,20,,3.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,20,,3.496,Percent of Total Billed Charges,20% of Total Billed Charges,4.37,20,,3.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,65,,11.36,Percent of Total Billed Charges,65% of Total Billed Charges,14.2,65,,11.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,53.67,
ELECTRODE ONE STEP-ADULT,2532587,CDM,272,RC,,,Outpatient,,,259.15,129.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.83,20,,41.464,Percent of Total Billed Charges,20% of Total Billed Charges,51.83,20,,41.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.83,20,,41.464,Percent of Total Billed Charges,20% of Total Billed Charges,51.83,20,,41.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.45,65,,134.76,Percent of Total Billed Charges,65% of Total Billed Charges,168.45,65,,134.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.83,168.45,
CATH FOLEY 16FR 30CC 3WAY,2532591,CDM,272,RC,,,Outpatient,,,36.98,18.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.04,65,,19.232,Percent of Total Billed Charges,65% of Total Billed Charges,24.04,65,,19.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,53.67,
IMMOBILIZER HEAD-CHILD,2532592,CDM,270,RC,,,Outpatient,,,15.35,7.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.07,20,,2.456,Percent of Total Billed Charges,20% of Total Billed Charges,3.07,20,,2.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.07,20,,2.456,Percent of Total Billed Charges,20% of Total Billed Charges,3.07,20,,2.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.98,65,,7.984,Percent of Total Billed Charges,65% of Total Billed Charges,9.98,65,,7.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.07,53.67,
CATH FOLEY 18FR 30CC 3WAY,2532593,CDM,272,RC,,,Outpatient,,,22.2,11.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.44,20,,3.552,Percent of Total Billed Charges,20% of Total Billed Charges,4.44,20,,3.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.44,20,,3.552,Percent of Total Billed Charges,20% of Total Billed Charges,4.44,20,,3.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.43,65,,11.544,Percent of Total Billed Charges,65% of Total Billed Charges,14.43,65,,11.544,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.44,53.67,
CATH FOLEY 14FR 30CC 2 WAY,2532595,CDM,272,RC,,,Outpatient,,,17.77,8.89,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.55,20,,2.84,Percent of Total Billed Charges,20% of Total Billed Charges,3.55,20,,2.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.55,20,,2.84,Percent of Total Billed Charges,20% of Total Billed Charges,3.55,20,,2.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.55,65,,9.24,Percent of Total Billed Charges,65% of Total Billed Charges,11.55,65,,9.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.55,53.67,
CATH FOLEY 10FR,2532596,CDM,272,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
CATH FOLEY 20FR 30ML 3WAY,2532597,CDM,272,RC,,,Outpatient,,,13.49,6.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.77,65,,7.016,Percent of Total Billed Charges,65% of Total Billed Charges,8.77,65,,7.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,53.67,
CATH FOLEY 12FR 2WAY,2532598,CDM,272,RC,,,Outpatient,,,38.57,19.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.07,65,,20.056,Percent of Total Billed Charges,65% of Total Billed Charges,25.07,65,,20.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,53.67,
CATH FOLEY 22FR 30CC 3WAY,2532599,CDM,272,RC,,,Outpatient,,,22.2,11.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.44,20,,3.552,Percent of Total Billed Charges,20% of Total Billed Charges,4.44,20,,3.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.44,20,,3.552,Percent of Total Billed Charges,20% of Total Billed Charges,4.44,20,,3.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.43,65,,11.544,Percent of Total Billed Charges,65% of Total Billed Charges,14.43,65,,11.544,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.44,53.67,
STATLOCK PICC DEVICE,2532614,CDM,272,RC,,,Outpatient,,,94.55,47.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.91,20,,15.128,Percent of Total Billed Charges,20% of Total Billed Charges,18.91,20,,15.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.91,20,,15.128,Percent of Total Billed Charges,20% of Total Billed Charges,18.91,20,,15.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.46,65,,49.168,Percent of Total Billed Charges,65% of Total Billed Charges,61.46,65,,49.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.91,61.46,
TUBE STOMACH 16FR SALEM SUMP,2532615,CDM,272,RC,,,Outpatient,,,58.97,29.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.79,20,,9.432,Percent of Total Billed Charges,20% of Total Billed Charges,11.79,20,,9.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.79,20,,9.432,Percent of Total Billed Charges,20% of Total Billed Charges,11.79,20,,9.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.33,65,,30.664,Percent of Total Billed Charges,65% of Total Billed Charges,38.33,65,,30.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.79,53.67,
TUBE STOMACH 10 FR SALEM SUMP,2532616,CDM,272,RC,,,Outpatient,,,112.37,56.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.47,20,,17.976,Percent of Total Billed Charges,20% of Total Billed Charges,22.47,20,,17.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.47,20,,17.976,Percent of Total Billed Charges,20% of Total Billed Charges,22.47,20,,17.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.04,65,,58.432,Percent of Total Billed Charges,65% of Total Billed Charges,73.04,65,,58.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.47,73.04,
KANGAROO EPUMP SPIKE SET,2532617,CDM,272,RC,,,Outpatient,,,19.67,9.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,20,,3.144,Percent of Total Billed Charges,20% of Total Billed Charges,3.93,20,,3.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,20,,3.144,Percent of Total Billed Charges,20% of Total Billed Charges,3.93,20,,3.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.79,65,,10.232,Percent of Total Billed Charges,65% of Total Billed Charges,12.79,65,,10.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,53.67,
CATH KIT 8FR FEMALE,2532621,CDM,272,RC,,,Outpatient,,,21.32,10.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.26,20,,3.408,Percent of Total Billed Charges,20% of Total Billed Charges,4.26,20,,3.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.26,20,,3.408,Percent of Total Billed Charges,20% of Total Billed Charges,4.26,20,,3.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.86,65,,11.088,Percent of Total Billed Charges,65% of Total Billed Charges,13.86,65,,11.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.26,53.67,
SUTURE 1637G,2532622,CDM,272,RC,,,Outpatient,,,145.82,72.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.16,20,,23.328,Percent of Total Billed Charges,20% of Total Billed Charges,29.16,20,,23.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.16,20,,23.328,Percent of Total Billed Charges,20% of Total Billed Charges,29.16,20,,23.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.78,65,,75.824,Percent of Total Billed Charges,65% of Total Billed Charges,94.78,65,,75.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.16,94.78,
SUTURE 699G,2532623,CDM,272,RC,,,Outpatient,,,65.71,32.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,13.14,20,,10.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.71,65,,34.168,Percent of Total Billed Charges,65% of Total Billed Charges,42.71,65,,34.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,53.67,
IRRIG SOL .9% SALINE 500ML,2532625,CDM,272,RC,,,Outpatient,,,5.87,2.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,20,,0.936,Percent of Total Billed Charges,20% of Total Billed Charges,1.17,20,,0.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,20,,0.936,Percent of Total Billed Charges,20% of Total Billed Charges,1.17,20,,0.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.82,65,,3.056,Percent of Total Billed Charges,65% of Total Billed Charges,3.82,65,,3.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,53.67,
PICC INSERTION KIT- 5FR,2532626,CDM,272,RC,,,Outpatient,,,178.29,89.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.66,20,,28.528,Percent of Total Billed Charges,20% of Total Billed Charges,35.66,20,,28.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.66,20,,28.528,Percent of Total Billed Charges,20% of Total Billed Charges,35.66,20,,28.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.89,65,,92.712,Percent of Total Billed Charges,65% of Total Billed Charges,115.89,65,,92.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.66,115.89,
PICC INSERTION KIT- 4FR,2532629,CDM,272,RC,,,Outpatient,,,975.41,487.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.08,20,,156.064,Percent of Total Billed Charges,20% of Total Billed Charges,195.08,20,,156.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.08,20,,156.064,Percent of Total Billed Charges,20% of Total Billed Charges,195.08,20,,156.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,634.02,65,,507.216,Percent of Total Billed Charges,65% of Total Billed Charges,634.02,65,,507.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,634.02,
DRESSING CHANGE KIT PICC LINE,2532630,CDM,272,RC,,,Outpatient,,,24.74,12.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,20,,3.96,Percent of Total Billed Charges,20% of Total Billed Charges,4.95,20,,3.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,20,,3.96,Percent of Total Billed Charges,20% of Total Billed Charges,4.95,20,,3.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.08,65,,12.864,Percent of Total Billed Charges,65% of Total Billed Charges,16.08,65,,12.864,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,53.67,
IRRIG TRAY W/ PISTON,2532631,CDM,272,RC,,,Outpatient,,,44.29,22.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.86,20,,7.088,Percent of Total Billed Charges,20% of Total Billed Charges,8.86,20,,7.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.86,20,,7.088,Percent of Total Billed Charges,20% of Total Billed Charges,8.86,20,,7.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.79,65,,23.032,Percent of Total Billed Charges,65% of Total Billed Charges,28.79,65,,23.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.86,53.67,
MEPILEX 3X3 BORDER,2532632,CDM,272,RC,,,Outpatient,,,13.51,6.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.78,65,,7.024,Percent of Total Billed Charges,65% of Total Billed Charges,8.78,65,,7.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,53.67,
MEPILEX 4X4 BORDER,2532633,CDM,272,RC,,,Outpatient,,,18.4,9.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.68,20,,2.944,Percent of Total Billed Charges,20% of Total Billed Charges,3.68,20,,2.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.68,20,,2.944,Percent of Total Billed Charges,20% of Total Billed Charges,3.68,20,,2.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.96,65,,9.568,Percent of Total Billed Charges,65% of Total Billed Charges,11.96,65,,9.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.68,53.67,
WOUND DSG FOAM (ALLEVYN),2532634,CDM,272,RC,,,Outpatient,,,36.57,18.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,20,,5.848,Percent of Total Billed Charges,20% of Total Billed Charges,7.31,20,,5.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,20,,5.848,Percent of Total Billed Charges,20% of Total Billed Charges,7.31,20,,5.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.77,65,,19.016,Percent of Total Billed Charges,65% of Total Billed Charges,23.77,65,,19.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,53.67,
MEPILEX 4x12 BORDER,2532635,CDM,272,RC,,,Outpatient,,,31.46,15.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.29,20,,5.032,Percent of Total Billed Charges,20% of Total Billed Charges,6.29,20,,5.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.29,20,,5.032,Percent of Total Billed Charges,20% of Total Billed Charges,6.29,20,,5.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.45,65,,16.36,Percent of Total Billed Charges,65% of Total Billed Charges,20.45,65,,16.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.29,53.67,
MEPILEX BORDER 9 x 9/ SACRUM,2532636,CDM,272,RC,,,Outpatient,,,86.52,43.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,56.24,
DRESSNG CHANGE KIT CENTRAL LINE,2532637,CDM,272,RC,,,Outpatient,,,27.55,13.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.51,20,,4.408,Percent of Total Billed Charges,20% of Total Billed Charges,5.51,20,,4.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.51,20,,4.408,Percent of Total Billed Charges,20% of Total Billed Charges,5.51,20,,4.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.91,65,,14.328,Percent of Total Billed Charges,65% of Total Billed Charges,17.91,65,,14.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.51,53.67,
MEPILEX BORDER 7 x 7/ SACRUM,2532638,CDM,272,RC,,,Outpatient,,,66.13,33.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.23,20,,10.584,Percent of Total Billed Charges,20% of Total Billed Charges,13.23,20,,10.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.23,20,,10.584,Percent of Total Billed Charges,20% of Total Billed Charges,13.23,20,,10.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.98,65,,34.384,Percent of Total Billed Charges,65% of Total Billed Charges,42.98,65,,34.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.23,53.67,
MEPILEX 6X6,2532639,CDM,272,RC,,,Outpatient,,,36.7,18.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,20,,5.872,Percent of Total Billed Charges,20% of Total Billed Charges,7.34,20,,5.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,20,,5.872,Percent of Total Billed Charges,20% of Total Billed Charges,7.34,20,,5.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.86,65,,19.088,Percent of Total Billed Charges,65% of Total Billed Charges,23.86,65,,19.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,53.67,
MEPILEX 9X9 HEEL,2532640,CDM,272,RC,,,Outpatient,,,59.48,29.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,20,,9.52,Percent of Total Billed Charges,20% of Total Billed Charges,11.9,20,,9.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,20,,9.52,Percent of Total Billed Charges,20% of Total Billed Charges,11.9,20,,9.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.66,65,,30.928,Percent of Total Billed Charges,65% of Total Billed Charges,38.66,65,,30.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,53.67,
DUO-DERM  6x6 EXTRA THIN,2532642,CDM,272,RC,,,Outpatient,,,29.05,14.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.81,20,,4.648,Percent of Total Billed Charges,20% of Total Billed Charges,5.81,20,,4.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.81,20,,4.648,Percent of Total Billed Charges,20% of Total Billed Charges,5.81,20,,4.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.88,65,,15.104,Percent of Total Billed Charges,65% of Total Billed Charges,18.88,65,,15.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.81,53.67,
PEDIALTYE 2 OZ,2532643,CDM,270,RC,,,Outpatient,,,5.46,2.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,20,,0.872,Percent of Total Billed Charges,20% of Total Billed Charges,1.09,20,,0.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,20,,0.872,Percent of Total Billed Charges,20% of Total Billed Charges,1.09,20,,0.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.55,65,,2.84,Percent of Total Billed Charges,65% of Total Billed Charges,3.55,65,,2.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,53.67,
IRRIG SOL WATER 1000ML,2532644,CDM,272,RC,,,Outpatient,,,4.53,2.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,20,,0.728,Percent of Total Billed Charges,20% of Total Billed Charges,0.91,20,,0.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,20,,0.728,Percent of Total Billed Charges,20% of Total Billed Charges,0.91,20,,0.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.94,65,,2.352,Percent of Total Billed Charges,65% of Total Billed Charges,2.94,65,,2.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,53.67,
DUO-DERM 4X4 THICK,2532645,CDM,272,RC,,,Outpatient,,,58.71,29.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,53.67,
DUO-DERM 3X3 EXTRA THIN,2532646,CDM,272,RC,,,Outpatient,,,26.37,13.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.14,65,,13.712,Percent of Total Billed Charges,65% of Total Billed Charges,17.14,65,,13.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,53.67,
LUBRICATING JELLY DOSE 2.7 GM,2532647,CDM,272,RC,,,Outpatient,,,2.32,1.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,20,,0.368,Percent of Total Billed Charges,20% of Total Billed Charges,0.46,20,,0.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,20,,0.368,Percent of Total Billed Charges,20% of Total Billed Charges,0.46,20,,0.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.51,65,,1.208,Percent of Total Billed Charges,65% of Total Billed Charges,1.51,65,,1.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,53.67,
BIO-PATCH 3/4in W/ 1.5 MM HOLE,2532648,CDM,272,RC,,,Outpatient,,,62.42,31.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.48,20,,9.984,Percent of Total Billed Charges,20% of Total Billed Charges,12.48,20,,9.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.48,20,,9.984,Percent of Total Billed Charges,20% of Total Billed Charges,12.48,20,,9.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.57,65,,32.456,Percent of Total Billed Charges,65% of Total Billed Charges,40.57,65,,32.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.48,53.67,
KANGAROO G-TUBE 24FR,2532649,CDM,272,RC,,,Outpatient,,,131.17,65.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.23,20,,20.984,Percent of Total Billed Charges,20% of Total Billed Charges,26.23,20,,20.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.23,20,,20.984,Percent of Total Billed Charges,20% of Total Billed Charges,26.23,20,,20.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.26,65,,68.208,Percent of Total Billed Charges,65% of Total Billed Charges,85.26,65,,68.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.23,85.26,
IV START KIT,2532650,CDM,258,RC,,,Outpatient,,,7.93,3.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,65,,4.12,Percent of Total Billed Charges,65% of Total Billed Charges,5.15,65,,4.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,53.67,
CALMOSEPTINE OINTMENT PK,2532651,CDM,272,RC,,,Outpatient,,,3.93,1.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,20,,0.632,Percent of Total Billed Charges,20% of Total Billed Charges,0.79,20,,0.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,20,,0.632,Percent of Total Billed Charges,20% of Total Billed Charges,0.79,20,,0.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.55,65,,2.04,Percent of Total Billed Charges,65% of Total Billed Charges,2.55,65,,2.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,53.67,
ALGINATE SHEET 4x4.75,2532652,CDM,250,RC,A6196,HCPCS,Outpatient,,,71.96,35.98,,46.77,65,,37.416,Percent of Total Billed Charges,65% of Total Billed Charges,48.93,68,,39.144,Percent of Total Billed Charges,68% of Total Billed Charges,7.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.39,20,,11.512,Percent of Total Billed Charges,20% of Total Billed Charges,14.39,20,,11.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,20,,11.512,Percent of Total Billed Charges,20% of Total Billed Charges,14.39,20,,11.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.77,65,,37.416,Percent of Total Billed Charges,65% of Total Billed Charges,46.77,65,,37.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.01,53.67,
ELECTRODE ONE STEP-PEDI,2532653,CDM,272,RC,,,Outpatient,,,259.15,129.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.83,20,,41.464,Percent of Total Billed Charges,20% of Total Billed Charges,51.83,20,,41.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.83,20,,41.464,Percent of Total Billed Charges,20% of Total Billed Charges,51.83,20,,41.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.45,65,,134.76,Percent of Total Billed Charges,65% of Total Billed Charges,168.45,65,,134.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.83,168.45,
EZ-IO 25MM SET,2532655,CDM,272,RC,,,Outpatient,,,198.64,99.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.12,65,,103.296,Percent of Total Billed Charges,65% of Total Billed Charges,129.12,65,,103.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,129.12,
CATH FOLEY 16FR  COUDE TIP,2532656,CDM,272,RC,,,Outpatient,,,39.45,19.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,20,,6.312,Percent of Total Billed Charges,20% of Total Billed Charges,7.89,20,,6.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,20,,6.312,Percent of Total Billed Charges,20% of Total Billed Charges,7.89,20,,6.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.64,65,,20.512,Percent of Total Billed Charges,65% of Total Billed Charges,25.64,65,,20.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,53.67,
CATH FOLEY 14FR 10CC COUDE TIP,2532657,CDM,272,RC,,,Outpatient,,,38.95,19.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.32,65,,20.256,Percent of Total Billed Charges,65% of Total Billed Charges,25.32,65,,20.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,53.67,
CATH FOLEY 18FR 10CC COUDE TIP,2532658,CDM,272,RC,,,Outpatient,,,38.95,19.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.32,65,,20.256,Percent of Total Billed Charges,65% of Total Billed Charges,25.32,65,,20.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,53.67,
WOUND DSG CLEAR (OPSITE) 10x14 CM,2532659,CDM,272,RC,,,Outpatient,,,5.89,2.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.83,65,,3.064,Percent of Total Billed Charges,65% of Total Billed Charges,3.83,65,,3.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
IV CATHETER 18/20G MULTI LUMEN,2532661,CDM,272,RC,,,Outpatient,,,64.38,32.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.85,65,,33.48,Percent of Total Billed Charges,65% of Total Billed Charges,41.85,65,,33.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,53.67,
IV CATHETER 20/22G MULTI LUMEN,2532662,CDM,272,RC,,,Outpatient,,,64.38,32.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.85,65,,33.48,Percent of Total Billed Charges,65% of Total Billed Charges,41.85,65,,33.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,53.67,
WOUND GELLING FIBER ( ALGICELL ),2532663,CDM,272,RC,,,Outpatient,,,39.98,19.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.99,65,,20.792,Percent of Total Billed Charges,65% of Total Billed Charges,25.99,65,,20.792,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,53.67,
"OPTIFOAM, DRESSING 4X4",2532664,CDM,272,RC,,,Outpatient,,,11.31,5.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.35,65,,5.88,Percent of Total Billed Charges,65% of Total Billed Charges,7.35,65,,5.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,53.67,
SUTURE 1654G,2532665,CDM,272,RC,,,Outpatient,,,88.89,44.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.78,20,,14.224,Percent of Total Billed Charges,20% of Total Billed Charges,17.78,20,,14.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.78,20,,14.224,Percent of Total Billed Charges,20% of Total Billed Charges,17.78,20,,14.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.78,65,,46.224,Percent of Total Billed Charges,65% of Total Billed Charges,57.78,65,,46.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.78,57.78,
DERMABOND MINI-ADHESIVE,2532666,CDM,272,RC,,,Outpatient,,,64.38,32.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,12.88,20,,10.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.85,65,,33.48,Percent of Total Billed Charges,65% of Total Billed Charges,41.85,65,,33.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,53.67,
IMMOBILIZER HEAD-ADULT,2532667,CDM,270,RC,,,Outpatient,,,35.29,17.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,20,,5.648,Percent of Total Billed Charges,20% of Total Billed Charges,7.06,20,,5.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,20,,5.648,Percent of Total Billed Charges,20% of Total Billed Charges,7.06,20,,5.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,65,,18.352,Percent of Total Billed Charges,65% of Total Billed Charges,22.94,65,,18.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,53.67,
IMMOBILIZER HEAD- INFANT,2532668,CDM,274,RC,,,Outpatient,,,35.29,17.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,20,,5.648,Percent of Total Billed Charges,20% of Total Billed Charges,7.06,20,,5.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,20,,5.648,Percent of Total Billed Charges,20% of Total Billed Charges,7.06,20,,5.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.23,80,,22.584,Percent of Total Billed Charges,80% of Total Billed Charges,30,85,,24,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,30,
CERVICAL COLLAR-ADULT,2532669,CDM,274,RC,L0174,HCPCS,Outpatient,,,61.18,30.59,,39.77,65,,31.816,Percent of Total Billed Charges,65% of Total Billed Charges,41.6,68,,33.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.94,80,,39.152,Percent of Total Billed Charges,80% of Total Billed Charges,52,85,,41.6,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,52,
CERVICAL COLLAR-PEDIATRIC,2532670,CDM,274,RC,L0120,HCPCS,Outpatient,,,61.12,30.56,,39.73,65,,31.784,Percent of Total Billed Charges,65% of Total Billed Charges,41.56,68,,33.248,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,20,,9.776,Percent of Total Billed Charges,20% of Total Billed Charges,12.22,20,,9.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,20,,9.776,Percent of Total Billed Charges,20% of Total Billed Charges,12.22,20,,9.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.9,80,,39.12,Percent of Total Billed Charges,80% of Total Billed Charges,51.95,85,,41.56,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,51.95,
DRESSING ABSORB 6X9,2532671,CDM,272,RC,,,Outpatient,,,54.45,27.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,20,,8.712,Percent of Total Billed Charges,20% of Total Billed Charges,10.89,20,,8.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,20,,8.712,Percent of Total Billed Charges,20% of Total Billed Charges,10.89,20,,8.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.39,65,,28.312,Percent of Total Billed Charges,65% of Total Billed Charges,35.39,65,,28.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,53.67,
OPTILOCK ABSORB DRESSING,2532672,CDM,272,RC,,,Outpatient,,,51.16,25.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.23,20,,8.184,Percent of Total Billed Charges,20% of Total Billed Charges,10.23,20,,8.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.23,20,,8.184,Percent of Total Billed Charges,20% of Total Billed Charges,10.23,20,,8.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.25,65,,26.6,Percent of Total Billed Charges,65% of Total Billed Charges,33.25,65,,26.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.23,53.67,
ISOLATION VITAL SIGNS KIT,2532673,CDM,272,RC,,,Outpatient,,,22.63,11.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.71,65,,11.768,Percent of Total Billed Charges,65% of Total Billed Charges,14.71,65,,11.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,53.67,
CATH KIT 5FR NEONATAL,2532675,CDM,272,RC,,,Outpatient,,,16.94,8.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,20,,2.712,Percent of Total Billed Charges,20% of Total Billed Charges,3.39,20,,2.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,20,,2.712,Percent of Total Billed Charges,20% of Total Billed Charges,3.39,20,,2.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.01,65,,8.808,Percent of Total Billed Charges,65% of Total Billed Charges,11.01,65,,8.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,53.67,
CERVICAL COLLAR COMFO-EZE,2532677,CDM,271,RC,,,Outpatient,,,92.24,46.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.45,20,,14.76,Percent of Total Billed Charges,20% of Total Billed Charges,18.45,20,,14.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.45,20,,14.76,Percent of Total Billed Charges,20% of Total Billed Charges,18.45,20,,14.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.96,65,,47.968,Percent of Total Billed Charges,65% of Total Billed Charges,59.96,65,,47.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.45,59.96,
EZ-IO 45MM SET,2532678,CDM,272,RC,,,Outpatient,,,198.64,99.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.12,65,,103.296,Percent of Total Billed Charges,65% of Total Billed Charges,129.12,65,,103.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,129.12,
CERVICAL COLLAR-INFANT,2532679,CDM,271,RC,,,Outpatient,,,37.39,18.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.48,20,,5.984,Percent of Total Billed Charges,20% of Total Billed Charges,7.48,20,,5.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.48,20,,5.984,Percent of Total Billed Charges,20% of Total Billed Charges,7.48,20,,5.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.3,65,,19.44,Percent of Total Billed Charges,65% of Total Billed Charges,24.3,65,,19.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.48,53.67,
STOMA POUCH 70mm-2 3/4,2532681,CDM,272,RC,,,Outpatient,,,35.43,17.72,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.09,20,,5.672,Percent of Total Billed Charges,20% of Total Billed Charges,7.09,20,,5.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.09,20,,5.672,Percent of Total Billed Charges,20% of Total Billed Charges,7.09,20,,5.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.03,65,,18.424,Percent of Total Billed Charges,65% of Total Billed Charges,23.03,65,,18.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.09,53.67,
STOMA WAFER 57mm- 2 1/4,2532682,CDM,272,RC,,,Outpatient,,,48.15,24.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.63,20,,7.704,Percent of Total Billed Charges,20% of Total Billed Charges,9.63,20,,7.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.63,20,,7.704,Percent of Total Billed Charges,20% of Total Billed Charges,9.63,20,,7.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.3,65,,25.04,Percent of Total Billed Charges,65% of Total Billed Charges,31.3,65,,25.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.63,53.67,
STOMA WAFER 70mm- 2 3/4,2532683,CDM,272,RC,,,Outpatient,,,39.04,19.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.81,20,,6.248,Percent of Total Billed Charges,20% of Total Billed Charges,7.81,20,,6.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.81,20,,6.248,Percent of Total Billed Charges,20% of Total Billed Charges,7.81,20,,6.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,65,,20.304,Percent of Total Billed Charges,65% of Total Billed Charges,25.38,65,,20.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.81,53.67,
CARRAKLENZ,2532684,CDM,272,RC,,,Outpatient,,,63.55,31.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.71,20,,10.168,Percent of Total Billed Charges,20% of Total Billed Charges,12.71,20,,10.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.71,20,,10.168,Percent of Total Billed Charges,20% of Total Billed Charges,12.71,20,,10.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.31,65,,33.048,Percent of Total Billed Charges,65% of Total Billed Charges,41.31,65,,33.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.71,53.67,
WOUND CONTACT LAYER (DERMANET),2532685,CDM,272,RC,,,Outpatient,,,17.2,8.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.44,20,,2.752,Percent of Total Billed Charges,20% of Total Billed Charges,3.44,20,,2.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.44,20,,2.752,Percent of Total Billed Charges,20% of Total Billed Charges,3.44,20,,2.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.18,65,,8.944,Percent of Total Billed Charges,65% of Total Billed Charges,11.18,65,,8.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.44,53.67,
POUCH UROSTOMY,2532686,CDM,272,RC,,,Outpatient,,,16.69,8.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.34,20,,2.672,Percent of Total Billed Charges,20% of Total Billed Charges,3.34,20,,2.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.34,20,,2.672,Percent of Total Billed Charges,20% of Total Billed Charges,3.34,20,,2.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.85,65,,8.68,Percent of Total Billed Charges,65% of Total Billed Charges,10.85,65,,8.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.34,53.67,
STOMA WAFER 32mm- 1 1/4,2532687,CDM,272,RC,,,Outpatient,,,20.6,10.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,53.67,
IODOFORM 1/4' X 15' PK STRIP,2532688,CDM,272,RC,,,Outpatient,,,20.6,10.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,53.67,
IODOFORM 1  X 5  PK STRIP,2532689,CDM,272,RC,,,Outpatient,,,24.21,12.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.84,20,,3.872,Percent of Total Billed Charges,20% of Total Billed Charges,4.84,20,,3.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.84,20,,3.872,Percent of Total Billed Charges,20% of Total Billed Charges,4.84,20,,3.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.74,65,,12.592,Percent of Total Billed Charges,65% of Total Billed Charges,15.74,65,,12.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.84,53.67,
CATH FOLEY 22FR 30CC,2532690,CDM,272,RC,,,Outpatient,,,51.14,25.57,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.23,20,,8.184,Percent of Total Billed Charges,20% of Total Billed Charges,10.23,20,,8.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.23,20,,8.184,Percent of Total Billed Charges,20% of Total Billed Charges,10.23,20,,8.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.24,65,,26.592,Percent of Total Billed Charges,65% of Total Billed Charges,33.24,65,,26.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.23,53.67,
CATH FOLEY 20FR COUDE,2532691,CDM,272,RC,,,Outpatient,,,101.97,50.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.39,66.28,
CYSTO BLADDER IRRIGATION SET,2532692,CDM,272,RC,,,Outpatient,,,30.49,15.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.1,20,,4.88,Percent of Total Billed Charges,20% of Total Billed Charges,6.1,20,,4.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.1,20,,4.88,Percent of Total Billed Charges,20% of Total Billed Charges,6.1,20,,4.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.82,65,,15.856,Percent of Total Billed Charges,65% of Total Billed Charges,19.82,65,,15.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.1,53.67,
IV ARMBOARD ADULT,2532693,CDM,270,RC,,,Outpatient,,,47.38,23.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.8,65,,24.64,Percent of Total Billed Charges,65% of Total Billed Charges,30.8,65,,24.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,53.67,
STOMA POUCH 57mm - 2 1/4,2532694,CDM,270,RC,,,Outpatient,,,14.88,7.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.98,20,,2.384,Percent of Total Billed Charges,20% of Total Billed Charges,2.98,20,,2.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.98,20,,2.384,Percent of Total Billed Charges,20% of Total Billed Charges,2.98,20,,2.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.67,65,,7.736,Percent of Total Billed Charges,65% of Total Billed Charges,9.67,65,,7.736,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.98,53.67,
POUCH AIO,2532695,CDM,272,RC,,,Outpatient,,,19.83,9.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.97,20,,3.176,Percent of Total Billed Charges,20% of Total Billed Charges,3.97,20,,3.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.97,20,,3.176,Percent of Total Billed Charges,20% of Total Billed Charges,3.97,20,,3.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.89,65,,10.312,Percent of Total Billed Charges,65% of Total Billed Charges,12.89,65,,10.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.97,53.67,
IODOFORM 1/2  X 5  PK STRIP,2532696,CDM,272,RC,,,Outpatient,,,15.3,7.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.06,20,,2.448,Percent of Total Billed Charges,20% of Total Billed Charges,3.06,20,,2.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.06,20,,2.448,Percent of Total Billed Charges,20% of Total Billed Charges,3.06,20,,2.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.95,65,,7.96,Percent of Total Billed Charges,65% of Total Billed Charges,9.95,65,,7.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.06,53.67,
PLAIN PACKING STRIP 1/2 X5,2532697,CDM,272,RC,,,Outpatient,,,15.02,7.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.76,65,,7.808,Percent of Total Billed Charges,65% of Total Billed Charges,9.76,65,,7.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,53.67,
DERMAL CURETTE 7MM,2532698,CDM,270,RC,,,Outpatient,,,27.74,13.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,65,,14.424,Percent of Total Billed Charges,65% of Total Billed Charges,18.03,65,,14.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,53.67,
DERMAL CURETTE 2MM,2532699,CDM,270,RC,,,Outpatient,,,27.74,13.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,65,,14.424,Percent of Total Billed Charges,65% of Total Billed Charges,18.03,65,,14.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,53.67,
MEPILEX HEEL 5X8,2532700,CDM,272,RC,,,Outpatient,,,54.59,27.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.48,65,,28.384,Percent of Total Billed Charges,65% of Total Billed Charges,35.48,65,,28.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,53.67,
PLAIN PKING STRIP 1 X5,2532701,CDM,272,RC,,,Outpatient,,,2.07,1.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,65,,1.08,Percent of Total Billed Charges,65% of Total Billed Charges,1.35,65,,1.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
UVC TRAY STERILE,2532987,CDM,272,RC,,,Outpatient,,,198.28,99.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,39.66,20,,31.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.88,65,,103.104,Percent of Total Billed Charges,65% of Total Billed Charges,128.88,65,,103.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,128.88,
IV-DEX 5% 500ML (2B0063Q),2535294,CDM,258,RC,,,Outpatient,,,55.62,27.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,53.67,
IV-LACT RING & 5% DEX 1000ML,2535299,CDM,258,RC,,,Outpatient,,,61.8,30.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
IV-DEX 5% & SOD. CHL. 0.2% 1000ML,2535867,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IV-SOD.CHL. 9% 50ML 4PK,2535887,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
CREAM BARRIER PROTECTION,2535925,CDM,271,RC,,,Outpatient,,,47.07,23.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.41,20,,7.528,Percent of Total Billed Charges,20% of Total Billed Charges,9.41,20,,7.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.41,20,,7.528,Percent of Total Billed Charges,20% of Total Billed Charges,9.41,20,,7.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.6,65,,24.48,Percent of Total Billed Charges,65% of Total Billed Charges,30.6,65,,24.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.41,53.67,
RHINO ROCKET LARGE,2535932,CDM,272,RC,,,Outpatient,,,132.9,66.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.58,20,,21.264,Percent of Total Billed Charges,20% of Total Billed Charges,26.58,20,,21.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.58,20,,21.264,Percent of Total Billed Charges,20% of Total Billed Charges,26.58,20,,21.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.39,65,,69.112,Percent of Total Billed Charges,65% of Total Billed Charges,86.39,65,,69.112,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.58,86.39,
RHINO ROCKET SMALL,2535933,CDM,272,RC,,,Outpatient,,,121,60.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.2,20,,19.36,Percent of Total Billed Charges,20% of Total Billed Charges,24.2,20,,19.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.2,20,,19.36,Percent of Total Billed Charges,20% of Total Billed Charges,24.2,20,,19.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.65,65,,62.92,Percent of Total Billed Charges,65% of Total Billed Charges,78.65,65,,62.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.2,78.65,
MEPILEX AG 4X4,2535945,CDM,272,RC,,,Outpatient,,,69.59,34.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.92,20,,11.136,Percent of Total Billed Charges,20% of Total Billed Charges,13.92,20,,11.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.92,20,,11.136,Percent of Total Billed Charges,20% of Total Billed Charges,13.92,20,,11.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.23,65,,36.184,Percent of Total Billed Charges,65% of Total Billed Charges,45.23,65,,36.184,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.92,53.67,
POSEY HEEL PROTECTOR BOOT,2535980,CDM,270,RC,,,Outpatient,,,277.07,138.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.41,20,,44.328,Percent of Total Billed Charges,20% of Total Billed Charges,55.41,20,,44.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.41,20,,44.328,Percent of Total Billed Charges,20% of Total Billed Charges,55.41,20,,44.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.1,65,,144.08,Percent of Total Billed Charges,65% of Total Billed Charges,180.1,65,,144.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,180.1,
PIGTAIL PNEUMO CATH KIT 5FR,2535981,CDM,272,RC,,,Outpatient,,,271.2,135.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.24,20,,43.392,Percent of Total Billed Charges,20% of Total Billed Charges,54.24,20,,43.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.24,20,,43.392,Percent of Total Billed Charges,20% of Total Billed Charges,54.24,20,,43.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.28,65,,141.024,Percent of Total Billed Charges,65% of Total Billed Charges,176.28,65,,141.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,176.28,
DUO-DERM 4X4 EXTRA THIN,2538846,CDM,272,RC,,,Outpatient,,,30.37,15.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.07,20,,4.856,Percent of Total Billed Charges,20% of Total Billed Charges,6.07,20,,4.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.07,20,,4.856,Percent of Total Billed Charges,20% of Total Billed Charges,6.07,20,,4.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.74,65,,15.792,Percent of Total Billed Charges,65% of Total Billed Charges,19.74,65,,15.792,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.07,53.67,
OXYGEN TUBING 7FT,2540016,CDM,270,RC,,,Outpatient,,,32.48,16.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,20,,5.2,Percent of Total Billed Charges,20% of Total Billed Charges,6.5,20,,5.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,20,,5.2,Percent of Total Billed Charges,20% of Total Billed Charges,6.5,20,,5.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.11,65,,16.888,Percent of Total Billed Charges,65% of Total Billed Charges,21.11,65,,16.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,53.67,
CATH FOLEY 16FR 2WAY,2550028,CDM,272,RC,,,Outpatient,,,38.57,19.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.07,65,,20.056,Percent of Total Billed Charges,65% of Total Billed Charges,25.07,65,,20.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,53.67,
CATH FOLEY 18FR 2WAY,2550029,CDM,272,RC,,,Outpatient,,,38.57,19.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,7.71,20,,6.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.07,65,,20.056,Percent of Total Billed Charges,65% of Total Billed Charges,25.07,65,,20.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,53.67,
EZ-IO 15MM SET,2550654,CDM,272,RC,,,Outpatient,,,198.64,99.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,39.73,20,,31.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.12,65,,103.296,Percent of Total Billed Charges,65% of Total Billed Charges,129.12,65,,103.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,129.12,
COLLAR VISTA  ADULT,2550701,CDM,274,RC,L0174,HCPCS,Outpatient,,,61.18,30.59,,39.77,65,,31.816,Percent of Total Billed Charges,65% of Total Billed Charges,41.6,68,,33.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.94,80,,39.152,Percent of Total Billed Charges,80% of Total Billed Charges,52,85,,41.6,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,52,
COLLAR VISTA  PED'S 3,2550702,CDM,274,RC,L0174,HCPCS,Outpatient,,,61.18,30.59,,39.77,65,,31.816,Percent of Total Billed Charges,65% of Total Billed Charges,41.6,68,,33.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,12.24,20,,9.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.94,80,,39.152,Percent of Total Billed Charges,80% of Total Billed Charges,52,85,,41.6,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,52,
MEDIHONEY PASTE TUBE 1.5,2562237,CDM,272,RC,,,Outpatient,,,147.35,73.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.47,20,,23.576,Percent of Total Billed Charges,20% of Total Billed Charges,29.47,20,,23.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.47,20,,23.576,Percent of Total Billed Charges,20% of Total Billed Charges,29.47,20,,23.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.78,65,,76.624,Percent of Total Billed Charges,65% of Total Billed Charges,95.78,65,,76.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.47,95.78,
DRESSING MEDIHONEY 4X5,2562238,CDM,272,RC,,,Outpatient,,,86.57,43.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,56.27,
MEDIHONEY PASTE TUBE 0.5,2562239,CDM,272,RC,,,Outpatient,,,11.75,5.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.35,20,,1.88,Percent of Total Billed Charges,20% of Total Billed Charges,2.35,20,,1.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.35,20,,1.88,Percent of Total Billed Charges,20% of Total Billed Charges,2.35,20,,1.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.64,65,,6.112,Percent of Total Billed Charges,65% of Total Billed Charges,7.64,65,,6.112,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.35,53.67,
DRESSING DEBRISOFT 4X4,2562240,CDM,272,RC,,,Outpatient,,,95.97,47.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.19,20,,15.352,Percent of Total Billed Charges,20% of Total Billed Charges,19.19,20,,15.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.19,20,,15.352,Percent of Total Billed Charges,20% of Total Billed Charges,19.19,20,,15.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.38,65,,49.904,Percent of Total Billed Charges,65% of Total Billed Charges,62.38,65,,49.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.19,62.38,
VASHE WOUND WASH,2562241,CDM,272,RC,,,Outpatient,,,86.57,43.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,56.27,
MAXORB AG 4X5,2562242,CDM,272,RC,,,Outpatient,,,86.57,43.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,56.27,
MAXORB AG RIBBON,2562243,CDM,272,RC,,,Outpatient,,,86.57,43.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,56.27,
DIBAETIC ULCER TEST,2562244,CDM,272,RC,,,Outpatient,,,36.5,18.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,20,,5.84,Percent of Total Billed Charges,20% of Total Billed Charges,7.3,20,,5.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,20,,5.84,Percent of Total Billed Charges,20% of Total Billed Charges,7.3,20,,5.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.73,65,,18.984,Percent of Total Billed Charges,65% of Total Billed Charges,23.73,65,,18.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,53.67,
PICC SKIN PROTECTANT,2562245,CDM,272,RC,,,Outpatient,,,8.18,4.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,20,,1.312,Percent of Total Billed Charges,20% of Total Billed Charges,1.64,20,,1.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,20,,1.312,Percent of Total Billed Charges,20% of Total Billed Charges,1.64,20,,1.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.32,65,,4.256,Percent of Total Billed Charges,65% of Total Billed Charges,5.32,65,,4.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,53.67,
J-10 FELT METATARSAL PAD,2562246,CDM,272,RC,,,Outpatient,,,86.57,43.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,56.27,
MAXORB RIBBON ES,2562247,CDM,272,RC,,,Outpatient,,,86.57,43.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,56.27,
DRESSING ENDOFORM 2X2,2562248,CDM,272,RC,,,Outpatient,,,90.06,45.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.01,20,,14.408,Percent of Total Billed Charges,20% of Total Billed Charges,18.01,20,,14.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.01,20,,14.408,Percent of Total Billed Charges,20% of Total Billed Charges,18.01,20,,14.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.54,65,,46.832,Percent of Total Billed Charges,65% of Total Billed Charges,58.54,65,,46.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.01,58.54,
MIRRAGEN 1.5x1.5,2562249,CDM,761,RC,A2002,HCPCS,Outpatient,,,1750,875.00,,1137.5,65,,910,Percent of Total Billed Charges,65% of Total Billed Charges,1190,68,,952,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350,20,,280,Percent of Total Billed Charges,20% of Total Billed Charges,350,20,,280,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350,20,,280,Percent of Total Billed Charges,20% of Total Billed Charges,350,20,,280,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1137.5,65,,910,Percent of Total Billed Charges,65% of Total Billed Charges,1137.5,65,,910,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1190,
"BOOT, CAST LG",2562250,CDM,272,RC,,,Outpatient,,,86.57,43.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,17.31,20,,13.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,56.27,65,,45.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.31,56.27,
"BOOT, CAST REG",2562251,CDM,272,RC,,,Outpatient,,,488.24,244.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.65,20,,78.12,Percent of Total Billed Charges,20% of Total Billed Charges,97.65,20,,78.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.65,20,,78.12,Percent of Total Billed Charges,20% of Total Billed Charges,97.65,20,,78.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.36,65,,253.888,Percent of Total Billed Charges,65% of Total Billed Charges,317.36,65,,253.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,317.36,
"BOOT, CAST XL",2562252,CDM,272,RC,,,Outpatient,,,172.84,86.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.57,20,,27.656,Percent of Total Billed Charges,20% of Total Billed Charges,34.57,20,,27.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.57,20,,27.656,Percent of Total Billed Charges,20% of Total Billed Charges,34.57,20,,27.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.35,65,,89.88,Percent of Total Billed Charges,65% of Total Billed Charges,112.35,65,,89.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.57,112.35,
BOOST VHC VANILLA,2562253,CDM,272,RC,,,Outpatient,,,16.64,8.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.33,20,,2.664,Percent of Total Billed Charges,20% of Total Billed Charges,3.33,20,,2.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.33,20,,2.664,Percent of Total Billed Charges,20% of Total Billed Charges,3.33,20,,2.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,65,,8.656,Percent of Total Billed Charges,65% of Total Billed Charges,10.82,65,,8.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.33,53.67,
SYRINGE 60ml IRRIGATION SYRINGE,2562254,CDM,272,RC,,,Outpatient,,,2.99,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,65,,1.552,Percent of Total Billed Charges,65% of Total Billed Charges,1.94,65,,1.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
ENFIT SYRINGE 60CC,2562255,CDM,272,RC,,,Outpatient,,,2.99,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,65,,1.552,Percent of Total Billed Charges,65% of Total Billed Charges,1.94,65,,1.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
ENFIT W/ DISTAL END,2562256,CDM,272,RC,,,Outpatient,,,2.99,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,65,,1.552,Percent of Total Billed Charges,65% of Total Billed Charges,1.94,65,,1.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
BANDAGE TUBIGRIP 3,2562257,CDM,272,RC,,,Outpatient,,,37.8,18.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.56,20,,6.048,Percent of Total Billed Charges,20% of Total Billed Charges,7.56,20,,6.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.56,20,,6.048,Percent of Total Billed Charges,20% of Total Billed Charges,7.56,20,,6.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.57,65,,19.656,Percent of Total Billed Charges,65% of Total Billed Charges,24.57,65,,19.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.56,53.67,
BANDAGE TUBIGRIP LG ANKLE,2562258,CDM,272,RC,,,Outpatient,,,42.36,21.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.47,20,,6.776,Percent of Total Billed Charges,20% of Total Billed Charges,8.47,20,,6.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.47,20,,6.776,Percent of Total Billed Charges,20% of Total Billed Charges,8.47,20,,6.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.53,65,,22.024,Percent of Total Billed Charges,65% of Total Billed Charges,27.53,65,,22.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.47,53.67,
BANDAGE TUBIGRIP LG KNEE,2562259,CDM,272,RC,,,Outpatient,,,45.6,22.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.12,20,,7.296,Percent of Total Billed Charges,20% of Total Billed Charges,9.12,20,,7.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.12,20,,7.296,Percent of Total Billed Charges,20% of Total Billed Charges,9.12,20,,7.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.64,65,,23.712,Percent of Total Billed Charges,65% of Total Billed Charges,29.64,65,,23.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.12,53.67,
CAST SYSTEM 3IN,2562260,CDM,272,RC,,,Outpatient,,,167.22,83.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.44,20,,26.752,Percent of Total Billed Charges,20% of Total Billed Charges,33.44,20,,26.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.44,20,,26.752,Percent of Total Billed Charges,20% of Total Billed Charges,33.44,20,,26.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.69,65,,86.952,Percent of Total Billed Charges,65% of Total Billed Charges,108.69,65,,86.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.44,108.69,
CAST SYSTEM 4IN,2562261,CDM,272,RC,,,Outpatient,,,171.37,85.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.27,20,,27.416,Percent of Total Billed Charges,20% of Total Billed Charges,34.27,20,,27.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.27,20,,27.416,Percent of Total Billed Charges,20% of Total Billed Charges,34.27,20,,27.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.39,65,,89.112,Percent of Total Billed Charges,65% of Total Billed Charges,111.39,65,,89.112,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.27,111.39,
TEST KIT HBA1C DISP. KIT,2562262,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EPIFIX 18MM DISC,2562263,CDM,272,RC,Q4186,HCPCS,Outpatient,,,744,372.00,,483.6,65,,386.88,Percent of Total Billed Charges,65% of Total Billed Charges,505.92,68,,404.736,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.8,20,,119.04,Percent of Total Billed Charges,20% of Total Billed Charges,148.8,20,,119.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.8,20,,119.04,Percent of Total Billed Charges,20% of Total Billed Charges,148.8,20,,119.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,483.6,65,,386.88,Percent of Total Billed Charges,65% of Total Billed Charges,483.6,65,,386.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,505.92,
ABDUCTION PILLOW,2562264,CDM,272,RC,,,Outpatient,,,265.98,132.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.2,20,,42.56,Percent of Total Billed Charges,20% of Total Billed Charges,53.2,20,,42.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.2,20,,42.56,Percent of Total Billed Charges,20% of Total Billed Charges,53.2,20,,42.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.89,65,,138.312,Percent of Total Billed Charges,65% of Total Billed Charges,172.89,65,,138.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.2,172.89,
ABDUCTION KNEE PILLOW NYORTHO,2562265,CDM,272,RC,,,Outpatient,,,157.08,78.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.42,20,,25.136,Percent of Total Billed Charges,20% of Total Billed Charges,31.42,20,,25.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.42,20,,25.136,Percent of Total Billed Charges,20% of Total Billed Charges,31.42,20,,25.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.1,65,,81.68,Percent of Total Billed Charges,65% of Total Billed Charges,102.1,65,,81.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.42,102.1,
EPIFIX 2X2,2562266,CDM,250,RC,Q4186,HCPCS,Outpatient,,,2660,1330.00,,1729,65,,1383.2,Percent of Total Billed Charges,65% of Total Billed Charges,1808.8,68,,1447.04,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532,20,,425.6,Percent of Total Billed Charges,20% of Total Billed Charges,532,20,,425.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532,20,,425.6,Percent of Total Billed Charges,20% of Total Billed Charges,532,20,,425.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1729,65,,1383.2,Percent of Total Billed Charges,65% of Total Billed Charges,1729,65,,1383.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1808.8,
EPIFIX 2X3,2562267,CDM,272,RC,Q4186,HCPCS,Outpatient,,,3240,1620.00,,2106,65,,1684.8,Percent of Total Billed Charges,65% of Total Billed Charges,2203.2,68,,1762.56,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,648,20,,518.4,Percent of Total Billed Charges,20% of Total Billed Charges,648,20,,518.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,648,20,,518.4,Percent of Total Billed Charges,20% of Total Billed Charges,648,20,,518.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2106,65,,1684.8,Percent of Total Billed Charges,65% of Total Billed Charges,2106,65,,1684.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2203.2,
EPIFIX 2X4,2562268,CDM,250,RC,Q4186,HCPCS,Outpatient,,,3640,1820.00,,2366,65,,1892.8,Percent of Total Billed Charges,65% of Total Billed Charges,2475.2,68,,1980.16,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,728,20,,582.4,Percent of Total Billed Charges,20% of Total Billed Charges,728,20,,582.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,728,20,,582.4,Percent of Total Billed Charges,20% of Total Billed Charges,728,20,,582.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2366,65,,1892.8,Percent of Total Billed Charges,65% of Total Billed Charges,2366,65,,1892.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2475.2,
EPIFIX 3X4,2562269,CDM,250,RC,Q4186,HCPCS,Outpatient,,,6485,3242.50,,3000,65,,2400,Percent of Total Billed Charges,65% of Total Billed Charges,3000,68,,2400,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1297,20,,1037.6,Percent of Total Billed Charges,20% of Total Billed Charges,1297,20,,1037.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1297,20,,1037.6,Percent of Total Billed Charges,20% of Total Billed Charges,1297,20,,1037.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4215.25,65,,3372.2,Percent of Total Billed Charges,65% of Total Billed Charges,4215.25,65,,3372.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,4215.25,
EPIFIX 4X4,2562270,CDM,250,RC,Q4186,HCPCS,Outpatient,,,8200,4100.00,,3000,65,,2400,Percent of Total Billed Charges,65% of Total Billed Charges,3000,68,,2400,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1640,20,,1312,Percent of Total Billed Charges,20% of Total Billed Charges,1640,20,,1312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1640,20,,1312,Percent of Total Billed Charges,20% of Total Billed Charges,1640,20,,1312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5330,65,,4264,Percent of Total Billed Charges,65% of Total Billed Charges,5330,65,,4264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,5330,
EPIFIX 5X6,2562271,CDM,250,RC,Q4186,HCPCS,Outpatient,,,15565,7782.50,,3000,65,,2400,Percent of Total Billed Charges,65% of Total Billed Charges,3000,68,,2400,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3113,20,,2490.4,Percent of Total Billed Charges,20% of Total Billed Charges,3113,20,,2490.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3113,20,,2490.4,Percent of Total Billed Charges,20% of Total Billed Charges,3113,20,,2490.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10117.25,65,,8093.8,Percent of Total Billed Charges,65% of Total Billed Charges,10117.25,65,,8093.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,10117.25,
EPIFIX 5X6,2562272,CDM,250,RC,Q4186,HCPCS,Outpatient,,,26045,13022.50,,3000,65,,2400,Percent of Total Billed Charges,65% of Total Billed Charges,3000,68,,2400,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5209,20,,4167.2,Percent of Total Billed Charges,20% of Total Billed Charges,5209,20,,4167.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5209,20,,4167.2,Percent of Total Billed Charges,20% of Total Billed Charges,5209,20,,4167.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16929.25,65,,13543.4,Percent of Total Billed Charges,65% of Total Billed Charges,16929.25,65,,13543.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,16929.25,
DRYSOL 20% 35ML,2562273,CDM,272,RC,,,Outpatient,,,68.91,34.46,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.78,20,,11.024,Percent of Total Billed Charges,20% of Total Billed Charges,13.78,20,,11.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.78,20,,11.024,Percent of Total Billed Charges,20% of Total Billed Charges,13.78,20,,11.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.79,65,,35.832,Percent of Total Billed Charges,65% of Total Billed Charges,44.79,65,,35.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.78,53.67,
"DM STICK, STERILE WOUND 6IN",2562274,CDM,272,RC,,,Outpatient,,,7.08,3.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,20,,1.136,Percent of Total Billed Charges,20% of Total Billed Charges,1.42,20,,1.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,20,,1.136,Percent of Total Billed Charges,20% of Total Billed Charges,1.42,20,,1.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,65,,3.68,Percent of Total Billed Charges,65% of Total Billed Charges,4.6,65,,3.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,53.67,
MIRRAGEN 2.5x2.5,2562275,CDM,761,RC,A2002,HCPCS,Outpatient,,,2237.5,1118.75,,1454.38,65,,1163.504,Percent of Total Billed Charges,65% of Total Billed Charges,1521.5,68,,1217.2,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,447.5,20,,358,Percent of Total Billed Charges,20% of Total Billed Charges,447.5,20,,358,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,447.5,20,,358,Percent of Total Billed Charges,20% of Total Billed Charges,447.5,20,,358,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1454.38,65,,1163.504,Percent of Total Billed Charges,65% of Total Billed Charges,1454.38,65,,1163.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1521.5,
MIRRAGEN 3.5x3.5,2562276,CDM,761,RC,A2002,HCPCS,Outpatient,,,3375,1687.50,,2193.75,65,,1755,Percent of Total Billed Charges,65% of Total Billed Charges,2295,68,,1836,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,20,,540,Percent of Total Billed Charges,20% of Total Billed Charges,675,20,,540,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,20,,540,Percent of Total Billed Charges,20% of Total Billed Charges,675,20,,540,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2193.75,65,,1755,Percent of Total Billed Charges,65% of Total Billed Charges,2193.75,65,,1755,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2295,
INR TEST STRIPS,2562277,CDM,272,RC,,,Outpatient,,,250.43,125.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.09,20,,40.072,Percent of Total Billed Charges,20% of Total Billed Charges,50.09,20,,40.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.09,20,,40.072,Percent of Total Billed Charges,20% of Total Billed Charges,50.09,20,,40.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.78,65,,130.224,Percent of Total Billed Charges,65% of Total Billed Charges,162.78,65,,130.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.09,162.78,
PEAK FLOW METER,2562278,CDM,272,RC,,,Outpatient,,,89.23,44.62,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.85,20,,14.28,Percent of Total Billed Charges,20% of Total Billed Charges,17.85,20,,14.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.85,20,,14.28,Percent of Total Billed Charges,20% of Total Billed Charges,17.85,20,,14.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58,65,,46.4,Percent of Total Billed Charges,65% of Total Billed Charges,58,65,,46.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.85,58,
MEPITEL 2X3,2562279,CDM,272,RC,,,Outpatient,,,37.04,18.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,20,,5.928,Percent of Total Billed Charges,20% of Total Billed Charges,7.41,20,,5.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,20,,5.928,Percent of Total Billed Charges,20% of Total Billed Charges,7.41,20,,5.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.08,65,,19.264,Percent of Total Billed Charges,65% of Total Billed Charges,24.08,65,,19.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,53.67,
MEPITEL 4X7,2562280,CDM,272,RC,,,Outpatient,,,96.05,48.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.21,20,,15.368,Percent of Total Billed Charges,20% of Total Billed Charges,19.21,20,,15.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.21,20,,15.368,Percent of Total Billed Charges,20% of Total Billed Charges,19.21,20,,15.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.43,65,,49.944,Percent of Total Billed Charges,65% of Total Billed Charges,62.43,65,,49.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.21,62.43,
DRAWTEX 4X4,2562281,CDM,272,RC,,,Outpatient,,,103.79,51.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.76,20,,16.608,Percent of Total Billed Charges,20% of Total Billed Charges,20.76,20,,16.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.76,20,,16.608,Percent of Total Billed Charges,20% of Total Billed Charges,20.76,20,,16.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.46,65,,53.968,Percent of Total Billed Charges,65% of Total Billed Charges,67.46,65,,53.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.76,67.46,
MESALT DRESSING 2X2,2562282,CDM,272,RC,,,Outpatient,,,9.37,4.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.09,65,,4.872,Percent of Total Billed Charges,65% of Total Billed Charges,6.09,65,,4.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,53.67,
MESALT RIBBON 3/4X39,2562283,CDM,272,RC,,,Outpatient,,,23.81,11.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.76,20,,3.808,Percent of Total Billed Charges,20% of Total Billed Charges,4.76,20,,3.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.76,20,,3.808,Percent of Total Billed Charges,20% of Total Billed Charges,4.76,20,,3.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,65,,12.384,Percent of Total Billed Charges,65% of Total Billed Charges,15.48,65,,12.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.76,53.67,
IODOSORB GEL 10GM,2562284,CDM,272,RC,,,Outpatient,,,98.95,49.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,20,,15.832,Percent of Total Billed Charges,20% of Total Billed Charges,19.79,20,,15.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,20,,15.832,Percent of Total Billed Charges,20% of Total Billed Charges,19.79,20,,15.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.32,65,,51.456,Percent of Total Billed Charges,65% of Total Billed Charges,64.32,65,,51.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,64.32,
AQUACEL 4X4 W/ BORDER,2562285,CDM,272,RC,,,Outpatient,,,65.3,32.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.06,20,,10.448,Percent of Total Billed Charges,20% of Total Billed Charges,13.06,20,,10.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.06,20,,10.448,Percent of Total Billed Charges,20% of Total Billed Charges,13.06,20,,10.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.45,65,,33.96,Percent of Total Billed Charges,65% of Total Billed Charges,42.45,65,,33.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.06,53.67,
"TRAY, TOE NAIL REMOVAL",2562286,CDM,272,RC,,,Outpatient,,,112,56.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.4,20,,17.92,Percent of Total Billed Charges,20% of Total Billed Charges,22.4,20,,17.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.4,20,,17.92,Percent of Total Billed Charges,20% of Total Billed Charges,22.4,20,,17.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.8,65,,58.24,Percent of Total Billed Charges,65% of Total Billed Charges,72.8,65,,58.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.4,72.8,
WEBRIL NS 4X4 ROLL,2562287,CDM,272,RC,,,Outpatient,,,11.31,5.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.35,65,,5.88,Percent of Total Billed Charges,65% of Total Billed Charges,7.35,65,,5.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,53.67,
ESMARK 4x9 STERILE,2562288,CDM,272,RC,,,Outpatient,,,28.74,14.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.75,20,,4.6,Percent of Total Billed Charges,20% of Total Billed Charges,5.75,20,,4.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.75,20,,4.6,Percent of Total Billed Charges,20% of Total Billed Charges,5.75,20,,4.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.68,65,,14.944,Percent of Total Billed Charges,65% of Total Billed Charges,18.68,65,,14.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.75,53.67,
GRAPHIX PL 3X3,2562289,CDM,272,RC,Q4133,HCPCS,Outpatient,,,744,372.00,,483.6,65,,386.88,Percent of Total Billed Charges,65% of Total Billed Charges,505.92,68,,404.736,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.8,20,,119.04,Percent of Total Billed Charges,20% of Total Billed Charges,148.8,20,,119.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.8,20,,119.04,Percent of Total Billed Charges,20% of Total Billed Charges,148.8,20,,119.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,483.6,65,,386.88,Percent of Total Billed Charges,65% of Total Billed Charges,483.6,65,,386.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,505.92,
GRAPHIX PL 2X3,2562290,CDM,272,RC,Q4133,HCPCS,Outpatient,,,5500,2750.00,,3000,65,,2400,Percent of Total Billed Charges,65% of Total Billed Charges,3000,68,,2400,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,20,,880,Percent of Total Billed Charges,20% of Total Billed Charges,1100,20,,880,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,20,,880,Percent of Total Billed Charges,20% of Total Billed Charges,1100,20,,880,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3575,65,,2860,Percent of Total Billed Charges,65% of Total Billed Charges,3575,65,,2860,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,3575,
GRAPHIX PL 3X4,2562291,CDM,636,RC,Q4133,HCPCS,Outpatient,,,3206,1603.00,,2083.9,65,,1667.12,Percent of Total Billed Charges,65% of Total Billed Charges,2180.08,68,,1744.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.2,20,,512.96,Percent of Total Billed Charges,20% of Total Billed Charges,641.2,20,,512.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.2,20,,512.96,Percent of Total Billed Charges,20% of Total Billed Charges,641.2,20,,512.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2564.8,80,,2051.84,Percent of Total Billed Charges,80% of Total Billed Charges,2725.1,85,,2180.08,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.2,2725.1,
GRAPHIX PRIME 16mm DISC,2562294,CDM,761,RC,Q4133,HCPCS,Outpatient,,,2970,1485.00,,1930.5,65,,1544.4,Percent of Total Billed Charges,65% of Total Billed Charges,2019.6,68,,1615.68,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,594,20,,475.2,Percent of Total Billed Charges,20% of Total Billed Charges,594,20,,475.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,594,20,,475.2,Percent of Total Billed Charges,20% of Total Billed Charges,594,20,,475.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1930.5,65,,1544.4,Percent of Total Billed Charges,65% of Total Billed Charges,1930.5,65,,1544.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2019.6,
KNEE ARTHROSCOPY PK,2562295,CDM,272,RC,,,Outpatient,,,335.1,167.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.02,20,,53.616,Percent of Total Billed Charges,20% of Total Billed Charges,67.02,20,,53.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.02,20,,53.616,Percent of Total Billed Charges,20% of Total Billed Charges,67.02,20,,53.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.82,65,,174.256,Percent of Total Billed Charges,65% of Total Billed Charges,217.82,65,,174.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,217.82,
SHOULDER ARTHRO PK,2562296,CDM,272,RC,,,Outpatient,,,397.57,198.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.51,20,,63.608,Percent of Total Billed Charges,20% of Total Billed Charges,79.51,20,,63.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.51,20,,63.608,Percent of Total Billed Charges,20% of Total Billed Charges,79.51,20,,63.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.42,65,,206.736,Percent of Total Billed Charges,65% of Total Billed Charges,258.42,65,,206.736,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,258.42,
DVT SLEEVE SM,2562791,CDM,272,RC,,,Outpatient,,,192.33,96.17,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.47,20,,30.776,Percent of Total Billed Charges,20% of Total Billed Charges,38.47,20,,30.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.47,20,,30.776,Percent of Total Billed Charges,20% of Total Billed Charges,38.47,20,,30.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.01,65,,100.008,Percent of Total Billed Charges,65% of Total Billed Charges,125.01,65,,100.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.47,125.01,
DVT SLEEVE MD,2562792,CDM,272,RC,,,Outpatient,,,128.43,64.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.69,20,,20.552,Percent of Total Billed Charges,20% of Total Billed Charges,25.69,20,,20.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.69,20,,20.552,Percent of Total Billed Charges,20% of Total Billed Charges,25.69,20,,20.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.48,65,,66.784,Percent of Total Billed Charges,65% of Total Billed Charges,83.48,65,,66.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.69,83.48,
DVT SLEEVE LG,2562793,CDM,272,RC,,,Outpatient,,,183.38,91.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.68,20,,29.344,Percent of Total Billed Charges,20% of Total Billed Charges,36.68,20,,29.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.68,20,,29.344,Percent of Total Billed Charges,20% of Total Billed Charges,36.68,20,,29.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.2,65,,95.36,Percent of Total Billed Charges,65% of Total Billed Charges,119.2,65,,95.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.68,119.2,
CATHILON 16G - IV,2562861,CDM,272,RC,,,Outpatient,,,14.11,7.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.17,65,,7.336,Percent of Total Billed Charges,65% of Total Billed Charges,9.17,65,,7.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,53.67,
DRESSING MEDIHONEY 2X2,2562882,CDM,272,RC,,,Outpatient,,,51.4,25.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.28,20,,8.224,Percent of Total Billed Charges,20% of Total Billed Charges,10.28,20,,8.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.28,20,,8.224,Percent of Total Billed Charges,20% of Total Billed Charges,10.28,20,,8.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.41,65,,26.728,Percent of Total Billed Charges,65% of Total Billed Charges,33.41,65,,26.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.28,53.67,
APPLICATION SKIN SUB TRK LG AM FT ER GEN,2563241,CDM,761,RC,15275,HCPCS,Outpatient,,,1750,875.00,,1137.5,65,,910,Percent of Total Billed Charges,65% of Total Billed Charges,1190,68,,952,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,350,20,,280,Percent of Total Billed Charges,20% of Total Billed Charges,350,20,,280,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350,20,,280,Percent of Total Billed Charges,20% of Total Billed Charges,350,20,,280,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1137.5,65,,910,Percent of Total Billed Charges,65% of Total Billed Charges,1137.5,65,,910,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1190,
APPLICATION SKIN SUB TRK LG AM FT ER GEN,2563242,CDM,761,RC,15275,HCPCS,Outpatient,,,1737,868.50,,1129.05,65,,903.24,Percent of Total Billed Charges,65% of Total Billed Charges,1181.16,68,,944.928,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,347.4,20,,277.92,Percent of Total Billed Charges,20% of Total Billed Charges,347.4,20,,277.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.4,20,,277.92,Percent of Total Billed Charges,20% of Total Billed Charges,347.4,20,,277.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1129.05,65,,903.24,Percent of Total Billed Charges,65% of Total Billed Charges,1129.05,65,,903.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1181.16,
CAT SURG ANES FAC,2820113,CDM,370,RC,,,Outpatient,,,358.44,179.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.69,20,,57.352,Percent of Total Billed Charges,20% of Total Billed Charges,71.69,20,,57.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.69,20,,57.352,Percent of Total Billed Charges,20% of Total Billed Charges,71.69,20,,57.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.99,65,,186.392,Percent of Total Billed Charges,65% of Total Billed Charges,232.99,65,,186.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,232.99,
CAT SURG ANEST PHY,2820115,CDM,379,RC,,,Outpatient,,,238.96,119.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.79,20,,38.232,Percent of Total Billed Charges,20% of Total Billed Charges,47.79,20,,38.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.79,20,,38.232,Percent of Total Billed Charges,20% of Total Billed Charges,47.79,20,,38.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.32,65,,124.256,Percent of Total Billed Charges,65% of Total Billed Charges,155.32,65,,124.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.79,155.32,
ENDO UPPER GI FAC,2820145,CDM,370,RC,,,Outpatient,,,824,412.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,535.6,
ENDO UPPER GI CRNA,2820147,CDM,964,RC,731,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,220,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,235,
ENDO LOWER FACILITY,2820159,CDM,370,RC,812,HCPCS,Outpatient,,,824,412.00,,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,560.32,68,,448.256,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,560.32,
ANES COMBINED UPPER-LOWER GI PX (FAC),2820160,CDM,370,RC,,,Outpatient,,,824,412.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,535.6,
ENDO LOWER CRNA,2820161,CDM,964,RC,812,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,132,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,141,
ANES COMBINED UPPER-LOWER GI PX (CRNA),2820162,CDM,964,RC,813,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,220,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,235,
ANES LOWER INTST ENDO DIAGNOSTIC (FAC),2820163,CDM,370,RC,,,Outpatient,,,824,412.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,535.6,
ANES LOWER INST ENDO DIAGNOSTIC (CRNA),2820164,CDM,964,RC,811,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,176,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,188,
OPEN LL ANK FT FAC,2820193,CDM,370,RC,,,Outpatient,,,875.71,437.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.14,20,,140.112,Percent of Total Billed Charges,20% of Total Billed Charges,175.14,20,,140.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.14,20,,140.112,Percent of Total Billed Charges,20% of Total Billed Charges,175.14,20,,140.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,569.21,65,,455.368,Percent of Total Billed Charges,65% of Total Billed Charges,569.21,65,,455.368,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,569.21,
OPEN LL ANK FT CRNA,2820195,CDM,964,RC,,,Outpatient,,,583.8,291.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
GANGLION CYST WR-FAC,2820203,CDM,370,RC,,,Outpatient,,,275.63,137.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.13,20,,44.104,Percent of Total Billed Charges,20% of Total Billed Charges,55.13,20,,44.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.13,20,,44.104,Percent of Total Billed Charges,20% of Total Billed Charges,55.13,20,,44.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.16,65,,143.328,Percent of Total Billed Charges,65% of Total Billed Charges,179.16,65,,143.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,179.16,
GANGLION CYST WR-CRN,2820207,CDM,964,RC,,,Outpatient,,,183.75,91.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
AGE EXTREMES,2820213,CDM,964,RC,99100,HCPCS,Outpatient,,,257.5,128.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
B/P MONITOR,2820215,CDM,271,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
CARDIAC MONITOR,2820221,CDM,271,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
PULSE OXIMETER,2820223,CDM,271,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
NASAL CANNULA OXYGEN,2820229,CDM,272,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
ET TUBE,2820237,CDM,272,RC,,,Outpatient,,,18.85,9.43,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.77,20,,3.016,Percent of Total Billed Charges,20% of Total Billed Charges,3.77,20,,3.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.77,20,,3.016,Percent of Total Billed Charges,20% of Total Billed Charges,3.77,20,,3.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.25,65,,9.8,Percent of Total Billed Charges,65% of Total Billed Charges,12.25,65,,9.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.77,53.67,
BAXTER ANES TUBING,2820243,CDM,272,RC,,,Outpatient,,,23.95,11.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,20,,3.832,Percent of Total Billed Charges,20% of Total Billed Charges,4.79,20,,3.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,20,,3.832,Percent of Total Billed Charges,20% of Total Billed Charges,4.79,20,,3.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,65,,12.456,Percent of Total Billed Charges,65% of Total Billed Charges,15.57,65,,12.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,53.67,
RESOLUTION CLIP,2820250,CDM,272,RC,,,Outpatient,,,782.8,391.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.56,20,,125.248,Percent of Total Billed Charges,20% of Total Billed Charges,156.56,20,,125.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.56,20,,125.248,Percent of Total Billed Charges,20% of Total Billed Charges,156.56,20,,125.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,508.82,65,,407.056,Percent of Total Billed Charges,65% of Total Billed Charges,508.82,65,,407.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,508.82,
SUCTION TIP YANKAUER,2820258,CDM,272,RC,,,Outpatient,,,14.11,7.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,2.82,20,,2.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.17,65,,7.336,Percent of Total Billed Charges,65% of Total Billed Charges,9.17,65,,7.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,53.67,
SPINAL TRAY/KIT,2820259,CDM,272,RC,,,Outpatient,,,86.62,43.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.32,20,,13.856,Percent of Total Billed Charges,20% of Total Billed Charges,17.32,20,,13.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.32,20,,13.856,Percent of Total Billed Charges,20% of Total Billed Charges,17.32,20,,13.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.3,65,,45.04,Percent of Total Billed Charges,65% of Total Billed Charges,56.3,65,,45.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.32,56.3,
NASAL C02/02 CANNULA,2820261,CDM,272,RC,,,Outpatient,,,66.95,33.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,53.67,
BITE BLOCK C02 CANNU,2820263,CDM,272,RC,,,Outpatient,,,81.37,40.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.89,65,,42.312,Percent of Total Billed Charges,65% of Total Billed Charges,52.89,65,,42.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,53.67,
ANESTH REPAIR OF HERNIA,2820264,CDM,964,RC,832,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,264,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,282,
61-90 MIN ANESTHESIA,2820265,CDM,370,RC,,,Outpatient,,,716.88,358.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.38,20,,114.704,Percent of Total Billed Charges,20% of Total Billed Charges,143.38,20,,114.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.38,20,,114.704,Percent of Total Billed Charges,20% of Total Billed Charges,143.38,20,,114.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.97,65,,372.776,Percent of Total Billed Charges,65% of Total Billed Charges,465.97,65,,372.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,465.97,
ANESTH SURG UPPER ABDOMEN,2820266,CDM,964,RC,790,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,329,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,308,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,329,
91-120 MIN ANESTHESIA,2820267,CDM,370,RC,,,Outpatient,,,887.86,443.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,20,,142.056,Percent of Total Billed Charges,20% of Total Billed Charges,177.57,20,,142.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,20,,142.056,Percent of Total Billed Charges,20% of Total Billed Charges,177.57,20,,142.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,577.11,65,,461.688,Percent of Total Billed Charges,65% of Total Billed Charges,577.11,65,,461.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,577.11,
ANESTH ANORECTAL SURGERY,2820268,CDM,964,RC,902,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,220,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,235,
31-60 MIN ANESTHESIA,2820269,CDM,370,RC,,,Outpatient,,,649.93,324.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.99,20,,103.992,Percent of Total Billed Charges,20% of Total Billed Charges,129.99,20,,103.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.99,20,,103.992,Percent of Total Billed Charges,20% of Total Billed Charges,129.99,20,,103.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,422.45,65,,337.96,Percent of Total Billed Charges,65% of Total Billed Charges,422.45,65,,337.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,422.45,
ANESTH RPR OF HERNIA LOWER ABD NON SPEC,2820270,CDM,964,RC,830,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,176,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,188,
121-150 MIN ANESTHESIA,2820271,CDM,370,RC,,,Outpatient,,,1058.84,529.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.77,20,,169.416,Percent of Total Billed Charges,20% of Total Billed Charges,211.77,20,,169.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.77,20,,169.416,Percent of Total Billed Charges,20% of Total Billed Charges,211.77,20,,169.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,688.25,65,,550.6,Percent of Total Billed Charges,65% of Total Billed Charges,688.25,65,,550.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,688.25,
ANES HEAD/NECK/PTRUNK,2820272,CDM,964,RC,300,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,220,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,235,
ANESTH SKIN EXT/PER/ATRUNK,2820273,CDM,964,RC,400,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,132,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,141,
ANESTH GENITALIA SURGERY,2820274,CDM,964,RC,920,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,132,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,141,
ANESTH UPPER LEG SURGERY,2820275,CDM,964,RC,1250,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,176,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,188,
ENDO UPPER GI FACILITY,2821145,CDM,370,RC,,,Outpatient,,,824,412.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,535.6,
ENDO LOWER INT FAC,2821159,CDM,370,RC,,,Outpatient,,,824,412.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,535.6,
ENDO LOWER INT CRNA,2821161,CDM,964,RC,812,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141,100,,,Fee Schedule,100% of Anesthesia,,,,,Other,Not Seperately Reimbusable,132,100,,,Fee Schedule,100% of CMS OPPs Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,141,
I & D DRAINAGE ABSCESS SIMPLE PRO,2900074,CDM,982,RC,10060,HCPCS,Outpatient,,,342.2,171.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,115.94,110,,,Fee Schedule,110% of Multiplan Fee Schedule,115.94,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,133.33,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,121.3,100,,,Case Rate,Pays Based on per visit rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid rate,68.7,133.33,
PORT FLUSH,2900075,CDM,761,RC,96523,HCPCS,Outpatient,,,451.14,225.57,,293.24,65,,234.592,Percent of Total Billed Charges,65% of Total Billed Charges,306.78,68,,245.424,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.23,20,,72.184,Percent of Total Billed Charges,20% of Total Billed Charges,90.23,20,,72.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.23,20,,72.184,Percent of Total Billed Charges,20% of Total Billed Charges,90.23,20,,72.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.24,65,,234.592,Percent of Total Billed Charges,65% of Total Billed Charges,293.24,65,,234.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,306.78,
CATARACT AMBUL SURG,2960203,CDM,360,RC,66984,HCPCS,Outpatient,,,3769.8,1884.90,,2450.37,65,,1960.296,Percent of Total Billed Charges,65% of Total Billed Charges,2563.46,68,,2050.768,Percent of Total Billed Charges,68% of Total Billed Charges,923,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,753.96,20,,603.168,Percent of Total Billed Charges,20% of Total Billed Charges,753.96,20,,603.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,753.96,20,,603.168,Percent of Total Billed Charges,20% of Total Billed Charges,753.96,20,,603.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2450.37,65,,1960.296,Percent of Total Billed Charges,65% of Total Billed Charges,2450.37,65,,1960.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2563.46,
COLONOSCOP W/BIOPS-COLD PRO FEE,2961000,CDM,982,RC,45380,HCPCS,Outpatient,,,1658.3,829.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,219.81,110,,,Fee Schedule,110% of Multiplan Fee Schedule,219.81,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,252.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,187.82,100,,,Case Rate,Pays Based on per visit rate,135.22,100,,,Fee Schedule,100% of FL Medicaid Rate,135.22,100,,,Fee Schedule,100% of FL Medicaid rate,135.22,252.78,
COLONOSCOP W/SNARE-PROFEE,2961020,CDM,982,RC,45385,HCPCS,Outpatient,,,1740.7,870.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,278.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,278.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,320.06,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,224.51,100,,,Case Rate,Pays Based on per visit rate,171.91,100,,,Fee Schedule,100% of FL Medicaid Rate,171.91,100,,,Fee Schedule,100% of FL Medicaid rate,171.91,320.06,
COLONOSCOPY-PRO FEE,2961040,CDM,982,RC,45378,HCPCS,Outpatient,,,1586.2,793.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,202.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,202.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,232.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,177.21,100,,,Case Rate,Pays Based on per visit rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid rate,124.61,232.99,
COLONOSCOPY DISCONTINUED-PROF FEE,2961050,CDM,982,RC,45378,HCPCS,Outpatient,,,309,154.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,202.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,202.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,232.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,177.21,100,,,Case Rate,Pays Based on per visit rate,124.61,100,,,Fee Schedule,100% of FL Medicaid Rate,124.61,100,,,Fee Schedule,100% of FL Medicaid rate,124.61,232.99,
EGD W/BIOPSY-PROFEE,2962000,CDM,982,RC,43239,HCPCS,Outpatient,,,1421.4,710.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,151.98,110,,,Fee Schedule,110% of Multiplan Fee Schedule,151.98,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,174.77,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,145.82,100,,,Case Rate,Pays Based on per visit rate,93.22,100,,,Fee Schedule,100% of FL Medicaid Rate,93.22,100,,,Fee Schedule,100% of FL Medicaid rate,93.22,174.77,
EGD W/O BIOPSY-PROF FEE,2962001,CDM,982,RC,43235,HCPCS,Outpatient,,,1411.1,705.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,134.4,110,,,Fee Schedule,110% of Multiplan Fee Schedule,134.4,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,154.56,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,135.44,100,,,Case Rate,Pays Based on per visit rate,82.84,100,,,Fee Schedule,100% of FL Medicaid Rate,82.84,100,,,Fee Schedule,100% of FL Medicaid rate,82.84,154.56,
INSERT NON-TUNNEL CV PROFEE,2962002,CDM,982,RC,36556,HCPCS,Outpatient,,,3616.3,1808.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,100,,,Fee Schedule,100% of FL Medicaid Rate,57,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,100,,,Fee Schedule,100% of FL Medicaid Rate,57,100,,,Fee Schedule,100% of FL Medicaid Rate,57,100,,,Fee Schedule,100% of FL Medicaid Rate,57,100,,,Fee Schedule,100% of FL Medicaid Rate,93.85,110,,,Fee Schedule,110% of Multiplan Fee Schedule,93.85,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,57,100,,,Fee Schedule,100% of FL Medicaid Rate,107.93,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,57,100,,,Fee Schedule,100% of FL Medicaid Rate,57,100,,,Fee Schedule,100% of FL Medicaid Rate,57,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,109.6,100,,,Case Rate,Pays Based on per visit rate,57,100,,,Fee Schedule,100% of FL Medicaid Rate,57,100,,,Fee Schedule,100% of FL Medicaid rate,57,109.6,
CHEMICAL CAUTER GRAN TISSUE,2962003,CDM,982,RC,17250,HCPCS,Outpatient,,,422.3,211.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,41.48,110,,,Fee Schedule,110% of Multiplan Fee Schedule,41.48,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,47.7,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,77.32,100,,,Case Rate,Pays Based on per visit rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid rate,24.72,77.32,
DEBRIDE SUBCU 1ST 20 CM/<,2962005,CDM,982,RC,11042,HCPCS,Outpatient,,,417.15,208.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,66.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,66.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,76.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,93.21,100,,,Case Rate,Pays Based on per visit rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid rate,40.61,93.21,
DEBRIDE-SUBCU ADD 20 CM,2962006,CDM,982,RC,11045,HCPCS,Outpatient,,,319.3,159.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,28.4,110,,,Fee Schedule,110% of Multiplan Fee Schedule,28.4,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,32.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.37,100,,,Case Rate,Pays Based on per visit rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid rate,17.77,70.37,
TANGENTIAL BX SKIN SING LESION P,2962007,CDM,982,RC,11102,HCPCS,Outpatient,,,360.5,180.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,41.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,41.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,47.5,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,77.98,100,,,Case Rate,Pays Based on per visit rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid rate,25.38,77.98,
PORTACATH,2962008,CDM,982,RC,36561,HCPCS,Outpatient,,,3893.25,1946.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,368.34,110,,,Fee Schedule,110% of Multiplan Fee Schedule,368.34,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,423.59,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,278.97,100,,,Case Rate,Pays Based on per visit rate,226.37,100,,,Fee Schedule,100% of FL Medicaid Rate,226.37,100,,,Fee Schedule,100% of FL Medicaid rate,226.37,423.59,
FLUORO CENTRAL VENOUS ACCESS PLACEMENT,2962009,CDM,982,RC,77001,HCPCS,Outpatient,,,127.72,63.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,103.64,110,,,Fee Schedule,110% of Multiplan Fee Schedule,103.64,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,119.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,99.01,100,,,Case Rate,Pays Based on per visit rate,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,46.41,100,,,Fee Schedule,100% of FL Medicaid rate,46.41,119.19,
EGD PERCUTANEOUS PLACEMENT G-TUBE,2962010,CDM,982,RC,43246,HCPCS,Outpatient,,,2327.25,1163.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,221.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,221.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,255.15,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,193.47,100,,,Case Rate,Pays Based on per visit rate,140.87,100,,,Fee Schedule,100% of FL Medicaid Rate,140.87,100,,,Fee Schedule,100% of FL Medicaid rate,140.87,255.15,
HEMORRHOIDECTOMY INTERNAL RUBBER BAND,2962011,CDM,982,RC,46221,HCPCS,Outpatient,,,1228.15,614.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,211.37,110,,,Fee Schedule,110% of Multiplan Fee Schedule,211.37,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,243.07,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,184.73,100,,,Case Rate,Pays Based on per visit rate,132.13,100,,,Fee Schedule,100% of FL Medicaid Rate,132.13,100,,,Fee Schedule,100% of FL Medicaid rate,132.13,243.07,
EXCISION OF ANAL TAG/PAPILLA,2962012,CDM,982,RC,46230,HCPCS,Outpatient,,,3301.65,1650.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,194.9,110,,,Fee Schedule,110% of Multiplan Fee Schedule,194.9,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,224.13,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,170.51,100,,,Case Rate,Pays Based on per visit rate,117.91,100,,,Fee Schedule,100% of FL Medicaid Rate,117.91,100,,,Fee Schedule,100% of FL Medicaid rate,117.91,224.13,
HEMORRHOIDECTOMY INTL/EXTL SINGLE GROUP,2962013,CDM,982,RC,46255,HCPCS,Outpatient,,,3509,1754.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,397.27,110,,,Fee Schedule,110% of Multiplan Fee Schedule,397.27,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,456.85,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,298.58,100,,,Case Rate,Pays Based on per visit rate,245.98,100,,,Fee Schedule,100% of FL Medicaid Rate,245.98,100,,,Fee Schedule,100% of FL Medicaid rate,245.98,456.85,
HEMORRHOIDECTOMY INTERNAL/EXTERNAL 2 >,2962014,CDM,982,RC,46260,HCPCS,Outpatient,,,3655.45,1827.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,540.82,110,,,Fee Schedule,110% of Multiplan Fee Schedule,540.82,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,621.94,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,397.89,100,,,Case Rate,Pays Based on per visit rate,345.29,100,,,Fee Schedule,100% of FL Medicaid Rate,345.29,100,,,Fee Schedule,100% of FL Medicaid rate,345.29,621.94,
REPAIR INITIAL ABDOMINAL WALL HERNIA,2962015,CDM,982,RC,49560,HCPCS,Outpatient,,,1083.56,541.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,581.76,100,,,Case Rate,Pays Based on per visit rate,529.16,100,,,Fee Schedule,100% of FL Medicaid Rate,529.16,100,,,Fee Schedule,100% of FL Medicaid rate,529.16,581.76,
REP INIT VENT/INCIS HERNIA OPEN INCARCER,2962016,CDM,982,RC,49561,HCPCS,Outpatient,,,1367.84,683.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,718.31,100,,,Case Rate,Pays Based on per visit rate,665.71,100,,,Fee Schedule,100% of FL Medicaid Rate,665.71,100,,,Fee Schedule,100% of FL Medicaid rate,665.71,718.31,
LAP REPAIR INCISIONAL HERNIA STRANGULATD,2962017,CDM,982,RC,49655,HCPCS,Outpatient,,,1501.74,750.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,794.63,100,,,Case Rate,Pays Based on per visit rate,742.03,100,,,Fee Schedule,100% of FL Medicaid Rate,742.03,100,,,Fee Schedule,100% of FL Medicaid rate,742.03,794.63,
LAP REP RECUR INCISIONL HERNIA REDUCIBLE,2962018,CDM,982,RC,49656,HCPCS,Outpatient,,,1349.3,674.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,710.39,100,,,Case Rate,Pays Based on per visit rate,657.79,100,,,Fee Schedule,100% of FL Medicaid Rate,657.79,100,,,Fee Schedule,100% of FL Medicaid rate,657.79,710.39,
LAP REPAIR RECURRENT INCISIONAL HERNIA,2962019,CDM,982,RC,49657,HCPCS,Outpatient,,,1948.76,974.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,996.93,100,,,Case Rate,Pays Based on per visit rate,944.33,100,,,Fee Schedule,100% of FL Medicaid Rate,944.33,100,,,Fee Schedule,100% of FL Medicaid rate,944.33,996.93,
REPAIR UMBILICAL HERNIA OPEN REDUCABLE,2962020,CDM,982,RC,49585,HCPCS,Outpatient,,,648.9,324.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,373.93,100,,,Case Rate,Pays Based on per visit rate,321.33,100,,,Fee Schedule,100% of FL Medicaid Rate,321.33,100,,,Fee Schedule,100% of FL Medicaid rate,321.33,373.93,
RPR UMBILICAL HERNIA 5YS />INCARCERATED,2962021,CDM,982,RC,49587,HCPCS,Outpatient,,,694.22,347.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,395.53,100,,,Case Rate,Pays Based on per visit rate,342.93,100,,,Fee Schedule,100% of FL Medicaid Rate,342.93,100,,,Fee Schedule,100% of FL Medicaid rate,342.93,395.53,
LAP REPAIR INITIAL INGUINAL HERNIA,2962022,CDM,982,RC,49650,HCPCS,Outpatient,,,6874.45,3437.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,495.67,110,,,Fee Schedule,110% of Multiplan Fee Schedule,495.67,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,570.02,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,362.79,100,,,Case Rate,Pays Based on per visit rate,310.19,100,,,Fee Schedule,100% of FL Medicaid Rate,310.19,100,,,Fee Schedule,100% of FL Medicaid rate,310.19,570.02,
LAP REPAIR RECURRENT INGUINAL HERNIA,2962023,CDM,982,RC,49651,HCPCS,Outpatient,,,7026.7,3513.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,647.52,110,,,Fee Schedule,110% of Multiplan Fee Schedule,647.52,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,744.64,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,456.4,100,,,Case Rate,Pays Based on per visit rate,403.8,100,,,Fee Schedule,100% of FL Medicaid Rate,403.8,100,,,Fee Schedule,100% of FL Medicaid rate,403.8,744.64,
LAP REPAIR INCISIONAL HERNIA REDUCIBLE,2962024,CDM,982,RC,49654,HCPCS,Outpatient,,,1242.18,621.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,658.08,100,,,Case Rate,Pays Based on per visit rate,605.48,100,,,Fee Schedule,100% of FL Medicaid Rate,605.48,100,,,Fee Schedule,100% of FL Medicaid rate,605.48,658.08,
LAP CHOLECYSTECTOMY WITH CHOLANGIOGRAM,2962025,CDM,982,RC,47563,HCPCS,Outpatient,,,5035,2517.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,824.45,110,,,Fee Schedule,110% of Multiplan Fee Schedule,824.45,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,948.12,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,568.56,100,,,Case Rate,Pays Based on per visit rate,515.96,100,,,Fee Schedule,100% of FL Medicaid Rate,515.96,100,,,Fee Schedule,100% of FL Medicaid rate,515.96,948.12,
CHOLECYSTECTOMY OPEN,2962026,CDM,982,RC,47600,HCPCS,Outpatient,,,1572.81,786.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,1226.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,1226.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,1410.91,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,818.87,100,,,Case Rate,Pays Based on per visit rate,766.27,100,,,Fee Schedule,100% of FL Medicaid Rate,766.27,100,,,Fee Schedule,100% of FL Medicaid rate,766.27,1410.91,
REPAIR INITIAL INGUIN HERNIA INCARCERATD,2962027,CDM,982,RC,49507,HCPCS,Outpatient,,,4423.95,2211.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,674.26,110,,,Fee Schedule,110% of Multiplan Fee Schedule,674.26,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,775.39,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,473.87,100,,,Case Rate,Pays Based on per visit rate,421.27,100,,,Fee Schedule,100% of FL Medicaid Rate,421.27,100,,,Fee Schedule,100% of FL Medicaid rate,421.27,775.39,
REPAIR RECURRENT INGUIN HERNIA REDUCIBLE,2962028,CDM,982,RC,49520,HCPCS,Outpatient,,,4550.1,2275.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,728.07,110,,,Fee Schedule,110% of Multiplan Fee Schedule,728.07,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,837.28,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,507.09,100,,,Case Rate,Pays Based on per visit rate,454.49,100,,,Fee Schedule,100% of FL Medicaid Rate,454.49,100,,,Fee Schedule,100% of FL Medicaid rate,454.49,837.28,
REPAIR RECURRENT INGUIN HERNIA INCARCERA,2962029,CDM,982,RC,49521,HCPCS,Outpatient,,,9181.4,4590.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,823.25,110,,,Fee Schedule,110% of Multiplan Fee Schedule,823.25,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,946.74,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,566.88,100,,,Case Rate,Pays Based on per visit rate,514.28,100,,,Fee Schedule,100% of FL Medicaid Rate,514.28,100,,,Fee Schedule,100% of FL Medicaid rate,514.28,946.74,
LAP CHOLE,2962030,CDM,982,RC,47562,HCPCS,Outpatient,,,7950,3975.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,758.02,110,,,Fee Schedule,110% of Multiplan Fee Schedule,758.02,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,871.72,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,526.81,100,,,Case Rate,Pays Based on per visit rate,474.21,100,,,Fee Schedule,100% of FL Medicaid Rate,474.21,100,,,Fee Schedule,100% of FL Medicaid rate,474.21,871.72,
CHOLECYSTECTOMY W/CHOLANGIOGRAPHY,2962031,CDM,982,RC,47605,HCPCS,Outpatient,,,1656.24,828.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,1293.19,110,,,Fee Schedule,110% of Multiplan Fee Schedule,1293.19,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,1487.17,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,861.34,100,,,Case Rate,Pays Based on per visit rate,808.74,100,,,Fee Schedule,100% of FL Medicaid Rate,808.74,100,,,Fee Schedule,100% of FL Medicaid rate,808.74,1487.17,
REP INIT INGUIN HERNIA AGE > 5 REDUCIBLE,2962032,CDM,360,RC,49505,HCPCS,Outpatient,,,7605,3802.50,,3000,65,,2400,Percent of Total Billed Charges,65% of Total Billed Charges,3000,68,,2400,Percent of Total Billed Charges,68% of Total Billed Charges,591,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,1521,20,,1216.8,Percent of Total Billed Charges,20% of Total Billed Charges,1521,20,,1216.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1521,20,,1216.8,Percent of Total Billed Charges,20% of Total Billed Charges,1521,20,,1216.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4943.25,65,,3954.6,Percent of Total Billed Charges,65% of Total Billed Charges,4943.25,65,,3954.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2069,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,4943.25,
INSERTION OF CHEST TUBE,2962033,CDM,982,RC,32551,HCPCS,Outpatient,,,229.69,114.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,174.57,110,,,Fee Schedule,110% of Multiplan Fee Schedule,174.57,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,200.76,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,163.23,100,,,Case Rate,Pays Based on per visit rate,110.63,100,,,Fee Schedule,100% of FL Medicaid Rate,110.63,100,,,Fee Schedule,100% of FL Medicaid rate,110.63,200.76,
APPENDECTOMY OPEN,2962034,CDM,982,RC,44950,HCPCS,Outpatient,,,945.54,472.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,737.1,110,,,Fee Schedule,110% of Multiplan Fee Schedule,737.1,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,847.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,512.89,100,,,Case Rate,Pays Based on per visit rate,460.29,100,,,Fee Schedule,100% of FL Medicaid Rate,460.29,100,,,Fee Schedule,100% of FL Medicaid rate,460.29,847.66,
APPENDECTOMY WITH OTHER MAJOR PROCEDURE,2962035,CDM,982,RC,44955,HCPCS,Outpatient,,,123.6,61.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,95.07,110,,,Fee Schedule,110% of Multiplan Fee Schedule,95.07,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,109.33,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,111.64,100,,,Case Rate,Pays Based on per visit rate,59.04,100,,,Fee Schedule,100% of FL Medicaid Rate,59.04,100,,,Fee Schedule,100% of FL Medicaid rate,59.04,111.64,
APPENDECTOMY RUP APP ABSCESS/PERITONITIS,2962036,CDM,982,RC,44960,HCPCS,Outpatient,,,1292.65,646.33,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,1006.72,110,,,Fee Schedule,110% of Multiplan Fee Schedule,1006.72,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,1157.73,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,682.32,100,,,Case Rate,Pays Based on per visit rate,629.72,100,,,Fee Schedule,100% of FL Medicaid Rate,629.72,100,,,Fee Schedule,100% of FL Medicaid rate,629.72,1157.73,
LAP APPENDECTOMY,2962037,CDM,982,RC,44970,HCPCS,Outpatient,,,5082,2541.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,690.28,110,,,Fee Schedule,110% of Multiplan Fee Schedule,690.28,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,793.83,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,484.81,100,,,Case Rate,Pays Based on per visit rate,432.21,100,,,Fee Schedule,100% of FL Medicaid Rate,432.21,100,,,Fee Schedule,100% of FL Medicaid rate,432.21,793.83,
REPAIR RECUR INCIS/VENT HERNIA REDUCIBLE,2962038,CDM,982,RC,49565,HCPCS,Outpatient,,,1127.85,563.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,603.36,100,,,Case Rate,Pays Based on per visit rate,550.76,100,,,Fee Schedule,100% of FL Medicaid Rate,550.76,100,,,Fee Schedule,100% of FL Medicaid rate,550.76,603.36,
REP RECUR INSIS/VENT HERNIA INCARCERATED,2962039,CDM,982,RC,49566,HCPCS,Outpatient,,,1380.2,690.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,724.07,100,,,Case Rate,Pays Based on per visit rate,671.47,100,,,Fee Schedule,100% of FL Medicaid Rate,671.47,100,,,Fee Schedule,100% of FL Medicaid rate,671.47,724.07,
PLACEMENT OF SETON DRAIN ANUS,2962040,CDM,982,RC,46020,HCPCS,Outpatient,,,3234.95,1617.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,131.1,110,,,Fee Schedule,110% of Multiplan Fee Schedule,131.1,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,150.76,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,201.01,100,,,Case Rate,Pays Based on per visit rate,148.41,100,,,Fee Schedule,100% of FL Medicaid Rate,148.41,100,,,Fee Schedule,100% of FL Medicaid rate,131.1,201.01,
SPHINCTEROTOMY FOR FISSURE,2962041,CDM,982,RC,46080,HCPCS,Outpatient,,,3282.8,1641.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,178.19,110,,,Fee Schedule,110% of Multiplan Fee Schedule,178.19,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,204.92,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,160.82,100,,,Case Rate,Pays Based on per visit rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid rate,108.22,204.92,
FISTULOTOMY SUBQ,2962042,CDM,982,RC,46270,HCPCS,Outpatient,,,3564.1,1782.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,447.34,110,,,Fee Schedule,110% of Multiplan Fee Schedule,447.34,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,514.44,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,326.2,100,,,Case Rate,Pays Based on per visit rate,273.6,100,,,Fee Schedule,100% of FL Medicaid Rate,273.6,100,,,Fee Schedule,100% of FL Medicaid rate,273.6,514.44,
OR I&D ABSCESS SKIN/SUBQ COMPLICATD/MULT,2962043,CDM,982,RC,10061,HCPCS,Outpatient,,,776.62,388.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,202.74,110,,,Fee Schedule,110% of Multiplan Fee Schedule,202.74,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,233.15,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,176.89,100,,,Case Rate,Pays Based on per visit rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid rate,124.29,233.15,
OR I & D PILONIDAL CYST SIMPLE,2962044,CDM,982,RC,10080,HCPCS,Outpatient,,,283.25,141.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,115.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,115.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,133.26,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,123.22,100,,,Case Rate,Pays Based on per visit rate,70.62,100,,,Fee Schedule,100% of FL Medicaid Rate,70.62,100,,,Fee Schedule,100% of FL Medicaid rate,70.62,133.26,
OR I & D PILONIDAL CYST/COMPLICATED,2962045,CDM,982,RC,10081,HCPCS,Outpatient,,,414.06,207.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,191.54,110,,,Fee Schedule,110% of Multiplan Fee Schedule,191.54,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,220.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,169.13,100,,,Case Rate,Pays Based on per visit rate,116.53,100,,,Fee Schedule,100% of FL Medicaid Rate,116.53,100,,,Fee Schedule,100% of FL Medicaid rate,116.53,220.27,
OR FB REMOVL INCISION SUBQ TISSUE SIMPLE,2962046,CDM,982,RC,10120,HCPCS,Outpatient,,,206,103.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,115.28,110,,,Fee Schedule,110% of Multiplan Fee Schedule,115.28,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,132.57,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,122.75,100,,,Case Rate,Pays Based on per visit rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid rate,70.15,132.57,
OR FB REM INCN SUBQ TISSUE COMPLICATED,2962047,CDM,982,RC,10121,HCPCS,Outpatient,,,1999.55,999.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,203.49,110,,,Fee Schedule,110% of Multiplan Fee Schedule,203.49,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,234.01,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,177.44,100,,,Case Rate,Pays Based on per visit rate,124.84,100,,,Fee Schedule,100% of FL Medicaid Rate,124.84,100,,,Fee Schedule,100% of FL Medicaid rate,124.84,234.01,
OR I&D HEMATOMA/SEROMA/FLUID COLLECTION,2962048,CDM,982,RC,10140,HCPCS,Outpatient,,,625.21,312.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,130.27,110,,,Fee Schedule,110% of Multiplan Fee Schedule,130.27,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,149.81,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,132.66,100,,,Case Rate,Pays Based on per visit rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid rate,80.06,149.81,
PUNCT ASPR ABSCESS/HEMATOMA/BULLA/CYSTS,2962049,CDM,982,RC,10160,HCPCS,Outpatient,,,549.55,274.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,105.9,110,,,Fee Schedule,110% of Multiplan Fee Schedule,105.9,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,121.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,116.98,100,,,Case Rate,Pays Based on per visit rate,64.38,100,,,Fee Schedule,100% of FL Medicaid Rate,64.38,100,,,Fee Schedule,100% of FL Medicaid rate,64.38,121.78,
EXCISION PILONIDAL CYST/SINUS SIMPLE,2962050,CDM,982,RC,11770,HCPCS,Outpatient,,,3350.95,1675.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,209.81,110,,,Fee Schedule,110% of Multiplan Fee Schedule,209.81,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,241.29,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,180.21,100,,,Case Rate,Pays Based on per visit rate,127.61,100,,,Fee Schedule,100% of FL Medicaid Rate,127.61,100,,,Fee Schedule,100% of FL Medicaid rate,127.61,241.29,
EXCISION PILONIDAL CYST/SINUS EXTENSIVE,2962051,CDM,982,RC,11771,HCPCS,Outpatient,,,3655.45,1827.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,508.37,110,,,Fee Schedule,110% of Multiplan Fee Schedule,508.37,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,584.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,357.55,100,,,Case Rate,Pays Based on per visit rate,304.95,100,,,Fee Schedule,100% of FL Medicaid Rate,304.95,100,,,Fee Schedule,100% of FL Medicaid rate,304.95,584.62,
EXCISION PILONIDAL CYST/SINUS COMPLICATD,2962052,CDM,982,RC,11772,HCPCS,Outpatient,,,3803.35,1901.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,649.88,110,,,Fee Schedule,110% of Multiplan Fee Schedule,649.88,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,747.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,451.88,100,,,Case Rate,Pays Based on per visit rate,399.28,100,,,Fee Schedule,100% of FL Medicaid Rate,399.28,100,,,Fee Schedule,100% of FL Medicaid rate,399.28,747.36,
PARING/CUTTING CORN/CALLUS/KERATOSIS 1,2962053,CDM,982,RC,11055,HCPCS,Outpatient,,,92.7,46.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,17.16,110,,,Fee Schedule,110% of Multiplan Fee Schedule,17.16,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,19.73,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,63.45,100,,,Case Rate,Pays Based on per visit rate,10.85,100,,,Fee Schedule,100% of FL Medicaid Rate,10.85,100,,,Fee Schedule,100% of FL Medicaid rate,10.85,63.45,
PARING/CUT CORN/CALLUS/KERATOSIS 2- 4,2962054,CDM,982,RC,11056,HCPCS,Outpatient,,,108.15,54.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,100,,,Fee Schedule,100% of FL Medicaid Rate,15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,100,,,Fee Schedule,100% of FL Medicaid Rate,15,100,,,Fee Schedule,100% of FL Medicaid Rate,15,100,,,Fee Schedule,100% of FL Medicaid Rate,15,100,,,Fee Schedule,100% of FL Medicaid Rate,24.21,110,,,Fee Schedule,110% of Multiplan Fee Schedule,24.21,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15,100,,,Fee Schedule,100% of FL Medicaid Rate,27.84,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15,100,,,Fee Schedule,100% of FL Medicaid Rate,15,100,,,Fee Schedule,100% of FL Medicaid Rate,15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.6,100,,,Case Rate,Pays Based on per visit rate,15,100,,,Fee Schedule,100% of FL Medicaid Rate,15,100,,,Fee Schedule,100% of FL Medicaid rate,15,67.6,
EXC BENIGN LESION TRUNK/ARM/LEG < 0.5 CM,2962055,CDM,982,RC,11400,HCPCS,Outpatient,,,872.9,436.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,91.98,110,,,Fee Schedule,110% of Multiplan Fee Schedule,91.98,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,105.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,108.37,100,,,Case Rate,Pays Based on per visit rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid rate,55.77,108.37,
OR SIMPLE REPAIR <2.5CM,2962056,CDM,982,RC,12001,HCPCS,Outpatient,,,124.63,62.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,50.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,50.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,58.59,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.92,100,,,Case Rate,Pays Based on per visit rate,30.32,100,,,Fee Schedule,100% of FL Medicaid Rate,30.32,100,,,Fee Schedule,100% of FL Medicaid rate,30.32,82.92,
PINCH GRAFT SINGLE/MULTIPLE,2962057,CDM,982,RC,15050,HCPCS,Outpatient,,,4751.65,2375.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,505.43,110,,,Fee Schedule,110% of Multiplan Fee Schedule,505.43,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,581.24,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,365.95,100,,,Case Rate,Pays Based on per visit rate,313.35,100,,,Fee Schedule,100% of FL Medicaid Rate,313.35,100,,,Fee Schedule,100% of FL Medicaid rate,313.35,581.24,
DESTRUCTION PREMALIGNANT LESION 1,2962058,CDM,982,RC,17000,HCPCS,Outpatient,,,95.79,47.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,59.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,59.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,68.54,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,88.98,100,,,Case Rate,Pays Based on per visit rate,36.38,100,,,Fee Schedule,100% of FL Medicaid Rate,36.38,100,,,Fee Schedule,100% of FL Medicaid rate,36.38,88.98,
AMPUTATION LEG ABOVE KNEE,2962059,CDM,982,RC,27590,HCPCS,Outpatient,,,1163.9,581.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,897.56,110,,,Fee Schedule,110% of Multiplan Fee Schedule,897.56,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,1032.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,613.68,100,,,Case Rate,Pays Based on per visit rate,561.08,100,,,Fee Schedule,100% of FL Medicaid Rate,561.08,100,,,Fee Schedule,100% of FL Medicaid rate,561.08,1032.19,
AMPUTATION LEG BELOW KNEE,2962060,CDM,982,RC,27880,HCPCS,Outpatient,,,1330.76,665.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,1026.06,110,,,Fee Schedule,110% of Multiplan Fee Schedule,1026.06,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,1179.97,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,693.83,100,,,Case Rate,Pays Based on per visit rate,641.23,100,,,Fee Schedule,100% of FL Medicaid Rate,641.23,100,,,Fee Schedule,100% of FL Medicaid rate,641.23,1179.97,
AMPUTATION FOOT TRANSMETATARSAL,2962061,CDM,982,RC,28805,HCPCS,Outpatient,,,1032.06,516.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,786.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,786.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,904.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,555.36,100,,,Case Rate,Pays Based on per visit rate,502.76,100,,,Fee Schedule,100% of FL Medicaid Rate,502.76,100,,,Fee Schedule,100% of FL Medicaid rate,502.76,904.27,
AMPUTATION TOE TRANSMET,2962062,CDM,982,RC,28810,HCPCS,Outpatient,,,4060,2030.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,471.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,471.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,542.34,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,353.54,100,,,Case Rate,Pays Based on per visit rate,300.94,100,,,Fee Schedule,100% of FL Medicaid Rate,300.94,100,,,Fee Schedule,100% of FL Medicaid rate,300.94,542.34,
REP INIT INGUIN HERNIA AGE > 5 REDUCIBLE,2962063,CDM,982,RC,49505,HCPCS,Outpatient,,,4423.95,2211.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,599.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,599.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,689.54,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,428.03,100,,,Case Rate,Pays Based on per visit rate,375.43,100,,,Fee Schedule,100% of FL Medicaid Rate,375.43,100,,,Fee Schedule,100% of FL Medicaid rate,375.43,689.54,
PARING/CUT BENIGN HYPERKERATOTIC LESN >4,2962064,CDM,982,RC,11057,HCPCS,Outpatient,,,220.4,110.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,31.61,110,,,Fee Schedule,110% of Multiplan Fee Schedule,31.61,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,36.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,71.98,100,,,Case Rate,Pays Based on per visit rate,19.38,100,,,Fee Schedule,100% of FL Medicaid Rate,19.38,100,,,Fee Schedule,100% of FL Medicaid rate,19.38,71.98,
DISARTICULATION KNEE,2962065,CDM,982,RC,27598,HCPCS,Outpatient,,,1034.12,517.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,789.8,110,,,Fee Schedule,110% of Multiplan Fee Schedule,789.8,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,908.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,552.24,100,,,Case Rate,Pays Based on per visit rate,499.64,100,,,Fee Schedule,100% of FL Medicaid Rate,499.64,100,,,Fee Schedule,100% of FL Medicaid rate,499.64,908.27,
TOTAL CONTACT LEG CAST,2962066,CDM,982,RC,29445,HCPCS,Outpatient,,,407.45,203.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,109.19,110,,,Fee Schedule,110% of Multiplan Fee Schedule,109.19,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,125.56,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,119.75,100,,,Case Rate,Pays Based on per visit rate,67.15,100,,,Fee Schedule,100% of FL Medicaid Rate,67.15,100,,,Fee Schedule,100% of FL Medicaid rate,67.15,125.56,
STRAPPING UNNA BOOT,2962067,CDM,982,RC,29580,HCPCS,Outpatient,,,216.3,108.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,29.36,110,,,Fee Schedule,110% of Multiplan Fee Schedule,29.36,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,33.76,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.55,100,,,Case Rate,Pays Based on per visit rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid rate,17.95,70.55,
APPLY MTLLAYR COMPRES LEG BELOW KNEE,2962068,CDM,983,RC,29581,HCPCS,Outpatient,,,293.55,146.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,28.69,110,,,Fee Schedule,110% of Multiplan Fee Schedule,28.69,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,32.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,71.06,100,,,Case Rate,Pays Based on per visit rate,18.46,100,,,Fee Schedule,100% of FL Medicaid Rate,18.46,100,,,Fee Schedule,100% of FL Medicaid rate,18.46,71.06,
SITE PREP TRUNK/ARM/LEG 1ST 100 CM,2962069,CDM,982,RC,15002,HCPCS,Outpatient,,,2263.45,1131.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,245.12,110,,,Fee Schedule,110% of Multiplan Fee Schedule,245.12,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,281.89,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,201.44,100,,,Case Rate,Pays Based on per visit rate,148.84,100,,,Fee Schedule,100% of FL Medicaid Rate,148.84,100,,,Fee Schedule,100% of FL Medicaid rate,148.84,281.89,
SITE PREP/SKIN GRAFT HEAD/HAND/FACE 1ST,2962070,CDM,982,RC,15004,HCPCS,Outpatient,,,984.55,492.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,287.03,110,,,Fee Schedule,110% of Multiplan Fee Schedule,287.03,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,330.09,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,229.59,100,,,Case Rate,Pays Based on per visit rate,176.99,100,,,Fee Schedule,100% of FL Medicaid Rate,176.99,100,,,Fee Schedule,100% of FL Medicaid rate,176.99,330.09,
THORACENTESIS NEEDLE/CATH W/O IMAGING,2962071,CDM,982,RC,32554,HCPCS,Outpatient,,,791.7,395.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,97.76,110,,,Fee Schedule,110% of Multiplan Fee Schedule,97.76,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,112.42,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,113.06,100,,,Case Rate,Pays Based on per visit rate,60.46,100,,,Fee Schedule,100% of FL Medicaid Rate,60.46,100,,,Fee Schedule,100% of FL Medicaid rate,60.46,113.06,
THORACENTESIS NEEDLE/CATH WITH IMAGING,2962072,CDM,982,RC,32555,HCPCS,Outpatient,,,813.45,406.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,119.24,110,,,Fee Schedule,110% of Multiplan Fee Schedule,119.24,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,137.13,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,126.66,100,,,Case Rate,Pays Based on per visit rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid rate,74.06,137.13,
CHOLECYSTOSTOMY W/DRAIN& STONE REMOVAL,2962073,CDM,982,RC,47480,HCPCS,Outpatient,,,1283.38,641.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,995.71,110,,,Fee Schedule,110% of Multiplan Fee Schedule,995.71,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,1145.07,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,632.43,100,,,Case Rate,Pays Based on per visit rate,579.83,100,,,Fee Schedule,100% of FL Medicaid Rate,579.83,100,,,Fee Schedule,100% of FL Medicaid rate,579.83,1145.07,
IMPLANT MESH OPEN HERNIA,2962074,CDM,982,RC,49568,HCPCS,Outpatient,,,397.58,198.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,241.95,100,,,Case Rate,Pays Based on per visit rate,189.35,100,,,Fee Schedule,100% of FL Medicaid Rate,189.35,100,,,Fee Schedule,100% of FL Medicaid rate,189.35,241.95,
LAP REPAIR VENTRAL REDUCIBLE HERNIA,2962075,CDM,982,RC,49652,HCPCS,Outpatient,,,1091.8,545.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,586.32,100,,,Case Rate,Pays Based on per visit rate,533.72,100,,,Fee Schedule,100% of FL Medicaid Rate,533.72,100,,,Fee Schedule,100% of FL Medicaid rate,533.72,586.32,
LAP REPAIR VENTRAL INCARCERATED HERNIA,2962076,CDM,982,RC,49653,HCPCS,Outpatient,,,1364.75,682.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,721.19,100,,,Case Rate,Pays Based on per visit rate,668.59,100,,,Fee Schedule,100% of FL Medicaid Rate,668.59,100,,,Fee Schedule,100% of FL Medicaid rate,668.59,721.19,
EGD FB REMOVAL,2962077,CDM,982,RC,43247,HCPCS,Outpatient,,,1197.7,598.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,193.99,110,,,Fee Schedule,110% of Multiplan Fee Schedule,193.99,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,223.08,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,172.13,100,,,Case Rate,Pays Based on per visit rate,119.53,100,,,Fee Schedule,100% of FL Medicaid Rate,119.53,100,,,Fee Schedule,100% of FL Medicaid rate,119.53,223.08,
EXCISION EXT PAPILLA /TAG ANUS,2962078,CDM,982,RC,46220,HCPCS,Outpatient,,,1442.75,721.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,135.81,110,,,Fee Schedule,110% of Multiplan Fee Schedule,135.81,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,156.18,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,134.7,100,,,Case Rate,Pays Based on per visit rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid rate,82.1,156.18,
HEMORRHOIDECTOMY EXT >2,2962079,CDM,982,RC,46250,HCPCS,Outpatient,,,3468.4,1734.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,356.14,110,,,Fee Schedule,110% of Multiplan Fee Schedule,356.14,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,409.56,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,272.59,100,,,Case Rate,Pays Based on per visit rate,219.99,100,,,Fee Schedule,100% of FL Medicaid Rate,219.99,100,,,Fee Schedule,100% of FL Medicaid rate,219.99,409.56,
EXCISION THROMBOSED HEMORRHOID EXT,2962080,CDM,982,RC,46320,HCPCS,Outpatient,,,1432.6,716.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,127.08,110,,,Fee Schedule,110% of Multiplan Fee Schedule,127.08,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,146.15,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,129.68,100,,,Case Rate,Pays Based on per visit rate,77.08,100,,,Fee Schedule,100% of FL Medicaid Rate,77.08,100,,,Fee Schedule,100% of FL Medicaid rate,77.08,146.15,
DEBRIDE OPEN WOUND < 20 CM,2962081,CDM,982,RC,97597,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,38.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,38.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,44.79,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.72,100,,,Case Rate,Pays Based on per visit rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid rate,18.12,70.72,
AVULSION NAIL PLATE PART/COMP SIMP 1,2962082,CDM,982,RC,11730,HCPCS,Outpatient,,,190.55,95.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,59.06,110,,,Fee Schedule,110% of Multiplan Fee Schedule,59.06,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,67.92,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,88.82,100,,,Case Rate,Pays Based on per visit rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid rate,36.22,88.82,
AVULSION NAIL PLATE PART/COMP SIMP ADDL,2962083,CDM,982,RC,11732,HCPCS,Outpatient,,,57.68,28.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,18.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,18.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,21.39,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,64.37,100,,,Case Rate,Pays Based on per visit rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid rate,11.77,64.37,
AMPUTATION TOE MP JOINT,2962084,CDM,982,RC,28820,HCPCS,Outpatient,,,3777.25,1888.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,197.8,110,,,Fee Schedule,110% of Multiplan Fee Schedule,197.8,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,227.47,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,274.11,100,,,Case Rate,Pays Based on per visit rate,221.51,100,,,Fee Schedule,100% of FL Medicaid Rate,221.51,100,,,Fee Schedule,100% of FL Medicaid rate,197.8,274.11,
AMPUTATION TOE INTERPHALANGEAL JOINT,2962085,CDM,982,RC,28825,HCPCS,Outpatient,,,3772.9,1886.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,192.92,110,,,Fee Schedule,110% of Multiplan Fee Schedule,192.92,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,221.86,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,260.2,100,,,Case Rate,Pays Based on per visit rate,207.6,100,,,Fee Schedule,100% of FL Medicaid Rate,207.6,100,,,Fee Schedule,100% of FL Medicaid rate,192.92,260.2,
INSERT INDWL TUNNLD PLEURAL CATH,2962086,CDM,982,RC,32550,HCPCS,Outpatient,,,4051.3,2025.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,225.23,110,,,Fee Schedule,110% of Multiplan Fee Schedule,225.23,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,259.01,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,190.82,100,,,Case Rate,Pays Based on per visit rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid rate,138.22,259.01,
PACEMAKER 1 LEAD,2962087,CDM,982,RC,33212,HCPCS,Outpatient,,,9751.25,4875.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,361.22,110,,,Fee Schedule,110% of Multiplan Fee Schedule,361.22,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,415.4,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,282.02,100,,,Case Rate,Pays Based on per visit rate,229.42,100,,,Fee Schedule,100% of FL Medicaid Rate,229.42,100,,,Fee Schedule,100% of FL Medicaid rate,229.42,415.4,
PACEMAKER 2 LEADS,2962088,CDM,982,RC,33213,HCPCS,Outpatient,,,12764.35,6382.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,378.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,378.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,435.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,291.86,100,,,Case Rate,Pays Based on per visit rate,239.26,100,,,Fee Schedule,100% of FL Medicaid Rate,239.26,100,,,Fee Schedule,100% of FL Medicaid rate,239.26,435.19,
PARACENTESIS NO IMAGING,2962089,CDM,982,RC,49082,HCPCS,Outpatient,,,1083.15,541.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,81.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,81.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,93.51,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,102.28,100,,,Case Rate,Pays Based on per visit rate,49.68,100,,,Fee Schedule,100% of FL Medicaid Rate,49.68,100,,,Fee Schedule,100% of FL Medicaid rate,49.68,102.28,
LAPAROSCOPIC CYST ASPIRATION,2962090,CDM,982,RC,49322,HCPCS,Outpatient,,,6806.3,3403.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,428.14,110,,,Fee Schedule,110% of Multiplan Fee Schedule,428.14,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,492.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,320.9,100,,,Case Rate,Pays Based on per visit rate,268.3,100,,,Fee Schedule,100% of FL Medicaid Rate,268.3,100,,,Fee Schedule,100% of FL Medicaid rate,268.3,492.36,
INPT SURG CONSULT LEVEL 1,2962091,CDM,982,RC,99221,HCPCS,Outpatient,,,154.5,77.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,184.04,109,,,Fee Schedule,109% of Multiplan Fee Schedule,184.04,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,105.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,122.44,100,,,Case Rate,Pays Based on per visit rate,69.84,100,,,Fee Schedule,100% of FL Medicaid Rate,69.84,100,,,Fee Schedule,100% of FL Medicaid rate,69.84,184.04,
INPT SURG CONSULT INITIAL LEVEL 2,2962092,CDM,982,RC,99222,HCPCS,Outpatient,,,208.06,104.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,287.15,109,,,Fee Schedule,109% of Multiplan Fee Schedule,287.15,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,165.1,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,146.43,100,,,Case Rate,Pays Based on per visit rate,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,93.83,100,,,Fee Schedule,100% of FL Medicaid rate,93.83,287.15,
INPT SURGICAL CONSULT INITIAL LEVEL 3,2962093,CDM,982,RC,99223,HCPCS,Outpatient,,,301.79,150.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,380.24,109,,,Fee Schedule,109% of Multiplan Fee Schedule,380.24,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,217.88,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,190.11,100,,,Case Rate,Pays Based on per visit rate,137.51,100,,,Fee Schedule,100% of FL Medicaid Rate,137.51,100,,,Fee Schedule,100% of FL Medicaid rate,137.51,380.24,
SUBSEQUENT SURG VISIT LEVEL 1,2962094,CDM,982,RC,99231,HCPCS,Outpatient,,,54.59,27.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,109.62,109,,,Fee Schedule,109% of Multiplan Fee Schedule,109.62,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,62.64,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,79.28,100,,,Case Rate,Pays Based on per visit rate,26.68,100,,,Fee Schedule,100% of FL Medicaid Rate,26.68,100,,,Fee Schedule,100% of FL Medicaid rate,26.68,109.62,
SUBSEQUENT HOSP VISIT LEVEL 2,2962095,CDM,982,RC,99232,HCPCS,Outpatient,,,99.91,49.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,173.3,109,,,Fee Schedule,109% of Multiplan Fee Schedule,173.3,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,99.21,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,102.04,100,,,Case Rate,Pays Based on per visit rate,49.44,100,,,Fee Schedule,100% of FL Medicaid Rate,49.44,100,,,Fee Schedule,100% of FL Medicaid rate,49.44,173.3,
SUBSEQUENT HOSP VISIT LEVEL 3,2962096,CDM,982,RC,99233,HCPCS,Outpatient,,,144.2,72.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,260.72,109,,,Fee Schedule,109% of Multiplan Fee Schedule,260.72,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,149.26,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,123.63,100,,,Case Rate,Pays Based on per visit rate,71.03,100,,,Fee Schedule,100% of FL Medicaid Rate,71.03,100,,,Fee Schedule,100% of FL Medicaid rate,71.03,260.72,
ED SURGICAL VISIT LEVEL 1,2962097,CDM,982,RC,99281,HCPCS,Outpatient,,,35.02,17.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,26.25,109,,,Fee Schedule,109% of Multiplan Fee Schedule,26.25,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.72,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,63.66,100,,,Case Rate,Pays Based on per visit rate,15.36,100,,,Fee Schedule,100% of FL Medicaid Rate,15.36,100,,,Fee Schedule,100% of FL Medicaid rate,14.72,459,
ED SURGUCAL VISIT LEVEL 2,2962098,CDM,982,RC,99282,HCPCS,Outpatient,,,66.95,33.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,93.59,109,,,Fee Schedule,109% of Multiplan Fee Schedule,93.59,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,53.57,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,78.06,100,,,Case Rate,Pays Based on per visit rate,29.76,100,,,Fee Schedule,100% of FL Medicaid Rate,29.76,100,,,Fee Schedule,100% of FL Medicaid rate,29.76,459,
ED SURGICAL VISIT LEVEL 3,2962099,CDM,982,RC,99283,HCPCS,Outpatient,,,99.91,49.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,160.2,109,,,Fee Schedule,109% of Multiplan Fee Schedule,160.2,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,91.21,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,94.1,100,,,Case Rate,Pays Based on per visit rate,45.8,100,,,Fee Schedule,100% of FL Medicaid Rate,45.8,100,,,Fee Schedule,100% of FL Medicaid rate,45.8,459,
ED SURGICAL VISIT LEVEL 4,2962100,CDM,982,RC,99284,HCPCS,Outpatient,,,168.92,84.46,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,270.47,109,,,Fee Schedule,109% of Multiplan Fee Schedule,270.47,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,155.25,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,132.45,100,,,Case Rate,Pays Based on per visit rate,84.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.15,100,,,Fee Schedule,100% of FL Medicaid rate,84.15,459,
ED SURGICAL VISIT LEVEL 5,2962101,CDM,982,RC,99285,HCPCS,Outpatient,,,245.14,122.57,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,393.31,109,,,Fee Schedule,109% of Multiplan Fee Schedule,393.31,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,224.97,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,459,100,,,Case Rate,Pays Based on Per visit rate,170.53,100,,,Case Rate,Pays Based on per visit rate,122.23,100,,,Fee Schedule,100% of FL Medicaid Rate,122.23,100,,,Fee Schedule,100% of FL Medicaid rate,122.23,459,
INITIAL SURG VISIT NH LEVEL 1,2962102,CDM,982,RC,99304,HCPCS,Outpatient,,,124.63,62.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,175.64,109,,,Fee Schedule,109% of Multiplan Fee Schedule,175.64,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,100.76,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,114.28,100,,,Case Rate,Pays Based on per visit rate,61.68,100,,,Fee Schedule,100% of FL Medicaid Rate,61.68,100,,,Fee Schedule,100% of FL Medicaid rate,61.68,175.64,
INITIAL SURG VISIT NH LEVEL 2,2962103,CDM,982,RC,99305,HCPCS,Outpatient,,,177.16,88.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,291.04,109,,,Fee Schedule,109% of Multiplan Fee Schedule,291.04,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,167.11,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,141.63,100,,,Case Rate,Pays Based on per visit rate,89.03,100,,,Fee Schedule,100% of FL Medicaid Rate,89.03,100,,,Fee Schedule,100% of FL Medicaid rate,89.03,291.04,
INITIAL SURG VISIT NH LEVEL 3,2962104,CDM,982,RC,99306,HCPCS,Outpatient,,,229.69,114.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,397.25,109,,,Fee Schedule,109% of Multiplan Fee Schedule,397.25,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,228.32,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,166.83,100,,,Case Rate,Pays Based on per visit rate,114.23,100,,,Fee Schedule,100% of FL Medicaid Rate,114.23,100,,,Fee Schedule,100% of FL Medicaid rate,114.23,397.25,
SUBSEQUENT SURG VISIT NH LEVEL 1,2962105,CDM,982,RC,99307,HCPCS,Outpatient,,,61.8,30.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,86.69,109,,,Fee Schedule,109% of Multiplan Fee Schedule,86.69,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,50.33,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.84,100,,,Case Rate,Pays Based on per visit rate,30.24,100,,,Fee Schedule,100% of FL Medicaid Rate,30.24,100,,,Fee Schedule,100% of FL Medicaid rate,30.24,86.69,
SUBSEQUENT SURG VISIT NH LEVEL 2,2962106,CDM,982,RC,99308,HCPCS,Outpatient,,,94.76,47.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,162.1,109,,,Fee Schedule,109% of Multiplan Fee Schedule,162.1,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,93.09,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,100.36,100,,,Case Rate,Pays Based on per visit rate,47.76,100,,,Fee Schedule,100% of FL Medicaid Rate,47.76,100,,,Fee Schedule,100% of FL Medicaid rate,47.76,162.1,
SUBSEQUENT SURG VISIT NH LEVEL 3,2962107,CDM,982,RC,99309,HCPCS,Outpatient,,,125.66,62.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,233.02,109,,,Fee Schedule,109% of Multiplan Fee Schedule,233.02,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,134.7,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,115.48,100,,,Case Rate,Pays Based on per visit rate,62.88,100,,,Fee Schedule,100% of FL Medicaid Rate,62.88,100,,,Fee Schedule,100% of FL Medicaid rate,62.88,233.02,
SUBSEQUENT SURG VISIT NH LEVEL 4,2962108,CDM,982,RC,99310,HCPCS,Outpatient,,,185.4,92.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,334.61,109,,,Fee Schedule,109% of Multiplan Fee Schedule,334.61,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,192.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,145.23,100,,,Case Rate,Pays Based on per visit rate,92.63,100,,,Fee Schedule,100% of FL Medicaid Rate,92.63,100,,,Fee Schedule,100% of FL Medicaid rate,92.63,334.61,
INS/DRAIN THROMBOSED HEMORRHOID,2962109,CDM,982,RC,46083,HCPCS,Outpatient,,,621.09,310.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,122.85,110,,,Fee Schedule,110% of Multiplan Fee Schedule,122.85,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,141.28,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,127.52,100,,,Case Rate,Pays Based on per visit rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid rate,74.92,141.28,
EXC H/F/NK/SP B9+MARG >4CM PRO FEE,2962110,CDM,982,RC,11426,HCPCS,Outpatient,,,3445.2,1722.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,298.19,110,,,Fee Schedule,110% of Multiplan Fee Schedule,298.19,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,342.92,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,237.2,100,,,Case Rate,Pays Based on per visit rate,184.6,100,,,Fee Schedule,100% of FL Medicaid Rate,184.6,100,,,Fee Schedule,100% of FL Medicaid rate,184.6,342.92,
EXC TR-EXT B9+MARG>4.0 CM PRO FEE,2962111,CDM,982,RC,11406,HCPCS,Outpatient,,,2074.95,1037.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,277.88,110,,,Fee Schedule,110% of Multiplan Fee Schedule,277.88,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,319.56,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,221.28,100,,,Case Rate,Pays Based on per visit rate,168.68,100,,,Fee Schedule,100% of FL Medicaid Rate,168.68,100,,,Fee Schedule,100% of FL Medicaid rate,168.68,319.56,
I & D OF VULVA OR PERINEAL ABSCE PRO FEE,2962112,CDM,982,RC,56405,HCPCS,Outpatient,,,498.8,249.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,140.46,110,,,Fee Schedule,110% of Multiplan Fee Schedule,140.46,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,161.53,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,134.7,100,,,Case Rate,Pays Based on per visit rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid rate,82.1,161.53,
EXC TR-EXT B9+MARG 3.1-4CM PRO FEE,2962113,CDM,982,RC,11404,HCPCS,Outpatient,,,1979.25,989.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111,100,,,Fee Schedule,100% of FL Medicaid Rate,111,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111,100,,,Fee Schedule,100% of FL Medicaid Rate,111,100,,,Fee Schedule,100% of FL Medicaid Rate,111,100,,,Fee Schedule,100% of FL Medicaid Rate,111,100,,,Fee Schedule,100% of FL Medicaid Rate,182.25,110,,,Fee Schedule,110% of Multiplan Fee Schedule,182.25,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,111,100,,,Fee Schedule,100% of FL Medicaid Rate,209.59,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,111,100,,,Fee Schedule,100% of FL Medicaid Rate,111,100,,,Fee Schedule,100% of FL Medicaid Rate,111,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,163.6,100,,,Case Rate,Pays Based on per visit rate,111,100,,,Fee Schedule,100% of FL Medicaid Rate,111,100,,,Fee Schedule,100% of FL Medicaid rate,111,209.59,
EXC TR-EXT B9+MARG 1.1-2CM PRO FEE,2962114,CDM,982,RC,11402,HCPCS,Outpatient,,,909.15,454.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,752,100,,,Fee Schedule,100% of Anesthesia,126.86,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,145.89,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,130.88,100,,,Case Rate,Pays Based on per visit rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid rate,78.28,752,
INTERNAL HRHC LIG W/O IMG PRO FEE,2962115,CDM,982,RC,46945,HCPCS,Outpatient,,,3493.05,1746.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,373.53,110,,,Fee Schedule,110% of Multiplan Fee Schedule,373.53,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,429.56,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,196.57,100,,,Case Rate,Pays Based on per visit rate,143.97,100,,,Fee Schedule,100% of FL Medicaid Rate,143.97,100,,,Fee Schedule,100% of FL Medicaid rate,143.97,429.56,
EXC RECTUM TUMOR,2962116,CDM,982,RC,45172,HCPCS,Outpatient,,,3445.2,1722.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,918.75,110,,,Fee Schedule,110% of Multiplan Fee Schedule,918.75,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,1056.57,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,637.88,100,,,Case Rate,Pays Based on per visit rate,585.28,100,,,Fee Schedule,100% of FL Medicaid Rate,585.28,100,,,Fee Schedule,100% of FL Medicaid rate,585.28,1056.57,
CIRCUM 28 DAYS OR OLDER,2962117,CDM,982,RC,54161,HCPCS,Outpatient,,,2475.15,1237.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,218.54,110,,,Fee Schedule,110% of Multiplan Fee Schedule,218.54,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,251.32,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,191.31,100,,,Case Rate,Pays Based on per visit rate,138.71,100,,,Fee Schedule,100% of FL Medicaid Rate,138.71,100,,,Fee Schedule,100% of FL Medicaid rate,138.71,251.32,
EXC TR-EXTM B9+MARG 2.1-3CM,2962118,CDM,982,RC,11403,HCPCS,Outpatient,,,679.8,339.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,164.66,110,,,Fee Schedule,110% of Multiplan Fee Schedule,164.66,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,189.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,152.98,100,,,Case Rate,Pays Based on per visit rate,100.38,100,,,Fee Schedule,100% of FL Medicaid Rate,100.38,100,,,Fee Schedule,100% of FL Medicaid rate,100.38,189.36,
VASECTOMY-PRO FEE,2963333,CDM,982,RC,55250,HCPCS,Outpatient,,,230,115.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,253,110,,,Fee Schedule,110% of Multiplan Fee Schedule,253,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,290.95,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,207.2,100,,,Case Rate,Pays Based on per visit rate,154.6,100,,,Fee Schedule,100% of FL Medicaid Rate,154.6,100,,,Fee Schedule,100% of FL Medicaid rate,154.6,290.95,
ACCU CHECKS,3000001,CDM,301,RC,82962,HCPCS,Outpatient,,,6.49,3.25,,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,4.41,68,,3.528,Percent of Total Billed Charges,68% of Total Billed Charges,4.49,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,1.3,20,,1.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,4.22,65,,3.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,50,,2.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,4.49,
ACETAMINOPHEN LIQ [650 MG/20.3 ML],3000002,CDM,637,RC,,,Outpatient,,,10.56,5.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.11,20,,1.688,Percent of Total Billed Charges,20% of Total Billed Charges,2.11,20,,1.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.11,20,,1.688,Percent of Total Billed Charges,20% of Total Billed Charges,2.11,20,,1.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,65,,5.488,Percent of Total Billed Charges,65% of Total Billed Charges,6.86,65,,5.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.11,53.67,
ACETAMINOPHEN SUPP [120 MG],3000003,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
ACETAMINOPHEN SUPP [650 MG],3000004,CDM,637,RC,,,Outpatient,,,5.97,2.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,20,,0.952,Percent of Total Billed Charges,20% of Total Billed Charges,1.19,20,,0.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,20,,0.952,Percent of Total Billed Charges,20% of Total Billed Charges,1.19,20,,0.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,65,,3.104,Percent of Total Billed Charges,65% of Total Billed Charges,3.88,65,,3.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,53.67,
ACETAMINOPHEN TAB [325 MG],3000005,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
ACETAMINOPHEN EXTRA STRENGTH TAB[500 MG],3000006,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
ACETYLCYSTEINE SOL 20% [200 MG/ML],3000007,CDM,636,RC,J0132,HCPCS,Outpatient,,,42.95,21.48,,,,,,Other,Not Seperately Reimbuasble,29.21,68,,23.368,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.59,20,,6.872,Percent of Total Billed Charges,20% of Total Billed Charges,8.59,20,,6.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.59,20,,6.872,Percent of Total Billed Charges,20% of Total Billed Charges,8.59,20,,6.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.36,80,,27.488,Percent of Total Billed Charges,80% of Total Billed Charges,36.51,85,,29.208,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.59,36.51,
ACTIVATED CHARCOAL SUS [25 GM]- PED,3000008,CDM,250,RC,,,Outpatient,,,152.9,76.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.58,20,,24.464,Percent of Total Billed Charges,20% of Total Billed Charges,30.58,20,,24.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.58,20,,24.464,Percent of Total Billed Charges,20% of Total Billed Charges,30.58,20,,24.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.39,65,,79.512,Percent of Total Billed Charges,65% of Total Billed Charges,99.39,65,,79.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.58,99.39,
ACTIVATED CHARCOAL SUS [50 GM]- ADULT,3000009,CDM,637,RC,,,Outpatient,,,121.8,60.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.36,20,,19.488,Percent of Total Billed Charges,20% of Total Billed Charges,24.36,20,,19.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.36,20,,19.488,Percent of Total Billed Charges,20% of Total Billed Charges,24.36,20,,19.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.17,65,,63.336,Percent of Total Billed Charges,65% of Total Billed Charges,79.17,65,,63.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.36,79.17,
ACYCLOVIR TAB [400 MG],3000010,CDM,637,RC,,,Outpatient,,,11.18,5.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,20,,1.792,Percent of Total Billed Charges,20% of Total Billed Charges,2.24,20,,1.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,20,,1.792,Percent of Total Billed Charges,20% of Total Billed Charges,2.24,20,,1.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.27,65,,5.816,Percent of Total Billed Charges,65% of Total Billed Charges,7.27,65,,5.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,53.67,
ADENOSINE INJ [6 MG/2 ML],3000011,CDM,636,RC,J0153,HCPCS,Outpatient,,,34.51,17.26,,,,,,Other,Not Seperately Reimbuasble,23.47,68,,18.776,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,20,,5.52,Percent of Total Billed Charges,20% of Total Billed Charges,6.9,20,,5.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,20,,5.52,Percent of Total Billed Charges,20% of Total Billed Charges,6.9,20,,5.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.61,80,,22.088,Percent of Total Billed Charges,80% of Total Billed Charges,29.33,85,,23.464,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,29.33,
ALBUMIN HUMAN [25 %] INJ - 100 ML,3000012,CDM,636,RC,P9046,HCPCS,Outpatient,,,454.95,227.48,,295.72,65,,236.576,Percent of Total Billed Charges,65% of Total Billed Charges,309.37,68,,247.496,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.99,20,,72.792,Percent of Total Billed Charges,20% of Total Billed Charges,90.99,20,,72.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.99,20,,72.792,Percent of Total Billed Charges,20% of Total Billed Charges,90.99,20,,72.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.96,80,,291.168,Percent of Total Billed Charges,80% of Total Billed Charges,386.71,85,,309.368,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.99,386.71,
ALLOPURINOL TAB [100 MG],3000013,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ALLOPURINOL TAB [300 MG],3000014,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ALPRAZolam TAB [0.25 MG],3000015,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
ALPRAZolam TAB [0.5 MG],3000016,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
ALTEPLASE - tPA [100 MG] INJ (BOLUS),3000017,CDM,636,RC,J2997,HCPCS,Outpatient,,,13639.11,6819.56,,8865.42,65,,7092.336,Percent of Total Billed Charges,65% of Total Billed Charges,9274.59,68,,7419.672,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2727.82,20,,2182.256,Percent of Total Billed Charges,20% of Total Billed Charges,2727.82,20,,2182.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2727.82,20,,2182.256,Percent of Total Billed Charges,20% of Total Billed Charges,2727.82,20,,2182.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10911.29,80,,8729.032,Percent of Total Billed Charges,80% of Total Billed Charges,11593.24,85,,9274.592,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2727.82,11593.24,
ALTEPLASE INJ [2 MG/2 ML],3000018,CDM,636,RC,J2997,HCPCS,Outpatient,,,756.74,378.37,,491.88,65,,393.504,Percent of Total Billed Charges,65% of Total Billed Charges,514.58,68,,411.664,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.35,20,,121.08,Percent of Total Billed Charges,20% of Total Billed Charges,151.35,20,,121.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.35,20,,121.08,Percent of Total Billed Charges,20% of Total Billed Charges,151.35,20,,121.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,605.39,80,,484.312,Percent of Total Billed Charges,80% of Total Billed Charges,643.23,85,,514.584,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.35,643.23,
AMIODARONE INJ [150MG/3 ML] SDV,3000019,CDM,637,RC,J0282,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
AMIODARONE TAB [200 MG],3000020,CDM,637,RC,,,Outpatient,,,40.94,20.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.19,20,,6.552,Percent of Total Billed Charges,20% of Total Billed Charges,8.19,20,,6.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.19,20,,6.552,Percent of Total Billed Charges,20% of Total Billed Charges,8.19,20,,6.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,65,,21.288,Percent of Total Billed Charges,65% of Total Billed Charges,26.61,65,,21.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.19,53.67,
AMITRIPTYLINE TAB [10 MG],3000021,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
AMITRIPTYLINE TAB [25 MG],3000022,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
amLODIPine TAB [10 MG],3000023,CDM,250,RC,,,Outpatient,,,11.64,5.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,20,,1.864,Percent of Total Billed Charges,20% of Total Billed Charges,2.33,20,,1.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,20,,1.864,Percent of Total Billed Charges,20% of Total Billed Charges,2.33,20,,1.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.57,65,,6.056,Percent of Total Billed Charges,65% of Total Billed Charges,7.57,65,,6.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,53.67,
amLODIPine TAB [2.5 MG],3000024,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
amLODIPine TAB [5 MG],3000025,CDM,250,RC,,,Outpatient,,,8.5,4.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,20,,1.36,Percent of Total Billed Charges,20% of Total Billed Charges,1.7,20,,1.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,20,,1.36,Percent of Total Billed Charges,20% of Total Billed Charges,1.7,20,,1.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,65,,4.424,Percent of Total Billed Charges,65% of Total Billed Charges,5.53,65,,4.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,53.67,
AMMON LACTATE 12% [225 GM] LOTION,3000026,CDM,250,RC,,,Outpatient,,,40.84,20.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.17,20,,6.536,Percent of Total Billed Charges,20% of Total Billed Charges,8.17,20,,6.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.17,20,,6.536,Percent of Total Billed Charges,20% of Total Billed Charges,8.17,20,,6.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.55,65,,21.24,Percent of Total Billed Charges,65% of Total Billed Charges,26.55,65,,21.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.17,53.67,
AMOXICIL/ CLAV TAB [875-125 MG],3000027,CDM,637,RC,,,Outpatient,,,26.06,13.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.21,20,,4.168,Percent of Total Billed Charges,20% of Total Billed Charges,5.21,20,,4.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.21,20,,4.168,Percent of Total Billed Charges,20% of Total Billed Charges,5.21,20,,4.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.94,65,,13.552,Percent of Total Billed Charges,65% of Total Billed Charges,16.94,65,,13.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.21,53.67,
AMOXICIL/CLAV [400-57.5 MG/5 ML] SUSP,3000028,CDM,637,RC,,,Outpatient,,,18.13,9.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.63,20,,2.904,Percent of Total Billed Charges,20% of Total Billed Charges,3.63,20,,2.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.63,20,,2.904,Percent of Total Billed Charges,20% of Total Billed Charges,3.63,20,,2.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.78,65,,9.424,Percent of Total Billed Charges,65% of Total Billed Charges,11.78,65,,9.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.63,53.67,
AMOXICIL/CLAV TAB [500-125 MG],3000029,CDM,637,RC,,,Outpatient,,,19.52,9.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,20,,3.12,Percent of Total Billed Charges,20% of Total Billed Charges,3.9,20,,3.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,20,,3.12,Percent of Total Billed Charges,20% of Total Billed Charges,3.9,20,,3.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.69,65,,10.152,Percent of Total Billed Charges,65% of Total Billed Charges,12.69,65,,10.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,53.67,
AMOXICILLIN CAP [500 MG],3000030,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
AMOXICILLIN SUSP [250 MG/5 ML],3000031,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
AMPICILLIN [1000 MG] IM INJ,3000032,CDM,636,RC,J0290,HCPCS,Outpatient,,,26.68,13.34,,,,,,Other,Not Seperately Reimbuasble,18.14,68,,14.512,Percent of Total Billed Charges,68% of Total Billed Charges,1.86,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.34,80,,17.072,Percent of Total Billed Charges,80% of Total Billed Charges,22.68,85,,18.144,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.86,22.68,
AMPICILLIN/NS IVPB : 2000MG/ 100ML,3000033,CDM,250,RC,,,Outpatient,,,26.68,13.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.34,65,,13.872,Percent of Total Billed Charges,65% of Total Billed Charges,17.34,65,,13.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.34,53.67,
AMPICILLIN [500 MG] IM INJ,3000034,CDM,636,RC,J0290,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,1.86,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.86,21.89,
AMPICILLIN/ SULB [3000 MG] IM INJ,3000035,CDM,636,RC,J0295,HCPCS,Outpatient,,,67.67,33.84,,,,,,Other,Not Seperately Reimbuasble,46.02,68,,36.816,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.53,20,,10.824,Percent of Total Billed Charges,20% of Total Billed Charges,13.53,20,,10.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.53,20,,10.824,Percent of Total Billed Charges,20% of Total Billed Charges,13.53,20,,10.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.14,80,,43.312,Percent of Total Billed Charges,80% of Total Billed Charges,57.52,85,,46.016,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.53,57.52,
APIXABAN [2.5 MG] TAB,3000036,CDM,637,RC,,,Outpatient,,,48.51,24.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,20,,7.76,Percent of Total Billed Charges,20% of Total Billed Charges,9.7,20,,7.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,20,,7.76,Percent of Total Billed Charges,20% of Total Billed Charges,9.7,20,,7.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.53,65,,25.224,Percent of Total Billed Charges,65% of Total Billed Charges,31.53,65,,25.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,53.67,
APIXABAN [5 MG] TAB,3000037,CDM,637,RC,,,Outpatient,,,48.51,24.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,20,,7.76,Percent of Total Billed Charges,20% of Total Billed Charges,9.7,20,,7.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,20,,7.76,Percent of Total Billed Charges,20% of Total Billed Charges,9.7,20,,7.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.53,65,,25.224,Percent of Total Billed Charges,65% of Total Billed Charges,31.53,65,,25.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,53.67,
ASPIRIN CHEW TAB [81 MG],3000038,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
ASPIRIN EC TAB [325 MG] Delayed Release,3000039,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
ASPIRIN EC TAB [81 MG] Delayed Release,3000040,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
ASPIRIN SUPP [300 MG],3000041,CDM,637,RC,,,Outpatient,,,13.08,6.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.62,20,,2.096,Percent of Total Billed Charges,20% of Total Billed Charges,2.62,20,,2.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.62,20,,2.096,Percent of Total Billed Charges,20% of Total Billed Charges,2.62,20,,2.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,65,,6.8,Percent of Total Billed Charges,65% of Total Billed Charges,8.5,65,,6.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.62,53.67,
ATENOLOL TAB [25 MG],3000042,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ATENOLOL TAB [50 MG],3000043,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ATORVASTATIN TAB [10 MG],3000044,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ATORVASTATIN TAB [20 MG],3000045,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ATORVASTATIN TAB [40 MG],3000046,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ATROPINE [1%] DRP,3000047,CDM,250,RC,,,Outpatient,,,91.88,45.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.38,20,,14.704,Percent of Total Billed Charges,20% of Total Billed Charges,18.38,20,,14.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.38,20,,14.704,Percent of Total Billed Charges,20% of Total Billed Charges,18.38,20,,14.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.72,65,,47.776,Percent of Total Billed Charges,65% of Total Billed Charges,59.72,65,,47.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.38,59.72,
ATROPINE INJ SYR [1 MG/10 ML],3000048,CDM,636,RC,J0461,HCPCS,Outpatient,,,30.69,15.35,,,,,,Other,Not Seperately Reimbuasble,20.87,68,,16.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.14,20,,4.912,Percent of Total Billed Charges,20% of Total Billed Charges,6.14,20,,4.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.14,20,,4.912,Percent of Total Billed Charges,20% of Total Billed Charges,6.14,20,,4.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.55,80,,19.64,Percent of Total Billed Charges,80% of Total Billed Charges,26.09,85,,20.872,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.14,26.09,
AZITHROMYCIN [500 MG] INJ SDV,3000049,CDM,636,RC,J0456,HCPCS,Outpatient,,,33.37,16.69,,,,,,Other,Not Seperately Reimbuasble,22.69,68,,18.152,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.7,80,,21.36,Percent of Total Billed Charges,80% of Total Billed Charges,28.36,85,,22.688,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,28.36,
AZITHROMYCIN SUSP [200 MG/5 ML],3000050,CDM,637,RC,,,Outpatient,,,12,6.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,53.67,
AZITHROMYCIN TAB [250 MG],3000051,CDM,637,RC,,,Outpatient,,,7.67,3.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.53,20,,1.224,Percent of Total Billed Charges,20% of Total Billed Charges,1.53,20,,1.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.53,20,,1.224,Percent of Total Billed Charges,20% of Total Billed Charges,1.53,20,,1.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,65,,3.992,Percent of Total Billed Charges,65% of Total Billed Charges,4.99,65,,3.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.53,53.67,
BACITRACIN OINT PACKET [0.9 GM],3000052,CDM,250,RC,,,Outpatient,,,2.75,1.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,20,,0.44,Percent of Total Billed Charges,20% of Total Billed Charges,0.55,20,,0.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,20,,0.44,Percent of Total Billed Charges,20% of Total Billed Charges,0.55,20,,0.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,65,,1.432,Percent of Total Billed Charges,65% of Total Billed Charges,1.79,65,,1.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,53.67,
BACLOFEN TAB [10 MG],3000053,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
BENZOCAINE/MENTHOL LOZ,3000054,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
BENZONATATE CAP [100 MG],3000055,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
BENZTROPINE TAB [1 MG],3000056,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
BISACODYL SUPP [10 MG],3000057,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
BISACODYL EC ORAL TAB [5 MG],3000058,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
BRIMONIDINE OPTH [0.2 %],3000059,CDM,637,RC,,,Outpatient,,,67.26,33.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.45,20,,10.76,Percent of Total Billed Charges,20% of Total Billed Charges,13.45,20,,10.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.45,20,,10.76,Percent of Total Billed Charges,20% of Total Billed Charges,13.45,20,,10.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.72,65,,34.976,Percent of Total Billed Charges,65% of Total Billed Charges,43.72,65,,34.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.45,53.67,
BUMETANIDE INJ [1 MG/4 ML],3000060,CDM,636,RC,J1939,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
BUMETANIDE INJ [2.5 MG/10 ML],3000061,CDM,636,RC,J1939,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
BUMETANIDE TAB [1 MG],3000062,CDM,637,RC,,,Outpatient,,,5.67,2.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.13,20,,0.904,Percent of Total Billed Charges,20% of Total Billed Charges,1.13,20,,0.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.13,20,,0.904,Percent of Total Billed Charges,20% of Total Billed Charges,1.13,20,,0.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,65,,2.952,Percent of Total Billed Charges,65% of Total Billed Charges,3.69,65,,2.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.13,53.67,
BUPIVACAINE [0.25 %] MDV,3000063,CDM,636,RC,J0665,HCPCS,Outpatient,,,106.13,53.07,,,,,,Other,Not Seperately Reimbuasble,72.17,68,,57.736,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.23,20,,16.984,Percent of Total Billed Charges,20% of Total Billed Charges,21.23,20,,16.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.23,20,,16.984,Percent of Total Billed Charges,20% of Total Billed Charges,21.23,20,,16.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.9,80,,67.92,Percent of Total Billed Charges,80% of Total Billed Charges,90.21,85,,72.168,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.23,90.21,
BUPIVACAINE W/EPINEPHRINE [0.5 %],3000064,CDM,636,RC,,,Outpatient,,,74.88,37.44,,,,,,Other,Not Seperately Reimbuasble,50.92,68,,40.736,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.98,20,,11.984,Percent of Total Billed Charges,20% of Total Billed Charges,14.98,20,,11.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.98,20,,11.984,Percent of Total Billed Charges,20% of Total Billed Charges,14.98,20,,11.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.9,80,,47.92,Percent of Total Billed Charges,80% of Total Billed Charges,63.65,85,,50.92,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.98,63.65,
buPROPion SR TAB [100 MG],3000065,CDM,250,RC,,,Outpatient,,,8.7,4.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.66,65,,4.528,Percent of Total Billed Charges,65% of Total Billed Charges,5.66,65,,4.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,53.67,
buPROPion SR TAB [150 MG],3000066,CDM,250,RC,,,Outpatient,,,9.99,5.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.49,65,,5.192,Percent of Total Billed Charges,65% of Total Billed Charges,6.49,65,,5.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,53.67,
buPROPion XL TAB [150 MG],3000067,CDM,250,RC,,,Outpatient,,,26.88,13.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.47,65,,13.976,Percent of Total Billed Charges,65% of Total Billed Charges,17.47,65,,13.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,53.67,
buPROPion XL TAB [300 MG],3000068,CDM,250,RC,,,Outpatient,,,14.42,7.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,53.67,
busPIRone TAB [15 MG],3000069,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
BUTAL/ACET/CAFF [50-325-40 MG] TAB,3000070,CDM,637,RC,,,Outpatient,,,15.14,7.57,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,20,,2.424,Percent of Total Billed Charges,20% of Total Billed Charges,3.03,20,,2.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,20,,2.424,Percent of Total Billed Charges,20% of Total Billed Charges,3.03,20,,2.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.84,65,,7.872,Percent of Total Billed Charges,65% of Total Billed Charges,9.84,65,,7.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,53.67,
CALAMINE/ZINC OXIDE LOTION,3000071,CDM,250,RC,,,Outpatient,,,15.86,7.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.31,65,,8.248,Percent of Total Billed Charges,65% of Total Billed Charges,10.31,65,,8.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,53.67,
CALCITRIOL CAP [0.25 MCG],3000072,CDM,637,RC,,,Outpatient,,,6.59,3.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.32,20,,1.056,Percent of Total Billed Charges,20% of Total Billed Charges,1.32,20,,1.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.32,20,,1.056,Percent of Total Billed Charges,20% of Total Billed Charges,1.32,20,,1.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.28,65,,3.424,Percent of Total Billed Charges,65% of Total Billed Charges,4.28,65,,3.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.32,53.67,
CALCIUM CARB TAB [500 MG],3000073,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
CALCIUM CARB/ VIT D TAB [600-400 IU],3000074,CDM,637,RC,,,Outpatient,,,13.8,6.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,20,,2.208,Percent of Total Billed Charges,20% of Total Billed Charges,2.76,20,,2.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,20,,2.208,Percent of Total Billed Charges,20% of Total Billed Charges,2.76,20,,2.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.97,65,,7.176,Percent of Total Billed Charges,65% of Total Billed Charges,8.97,65,,7.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,53.67,
CALCIUM CARBONATE [500 MG] CHEW TAB,3000075,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
CALCIUM CL 10% INJ [10 ML SYR],3000076,CDM,636,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
CALCIUM GLUC 10% IVPB [1 GM/50 ML],3000077,CDM,636,RC,J0612,HCPCS,Outpatient,,,50.93,25.47,,,,,,Other,Not Seperately Reimbuasble,34.63,68,,27.704,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,20,,8.152,Percent of Total Billed Charges,20% of Total Billed Charges,10.19,20,,8.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,20,,8.152,Percent of Total Billed Charges,20% of Total Billed Charges,10.19,20,,8.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.74,80,,32.592,Percent of Total Billed Charges,80% of Total Billed Charges,43.29,85,,34.632,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,43.29,
CALCIUM GLUCONATE INJ [1000MG/10 ML] SDV,3000078,CDM,250,RC,J0612,HCPCS,Outpatient,,,16.48,8.24,,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,11.21,68,,8.968,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,53.67,
CAMPHOR / MENTHOL / EUCALYPTUS,3000079,CDM,250,RC,,,Outpatient,,,9.37,4.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,1.87,20,,1.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.09,65,,4.872,Percent of Total Billed Charges,65% of Total Billed Charges,6.09,65,,4.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,53.67,
CAPTOPRIL TAB [25 MG],3000080,CDM,637,RC,,,Outpatient,,,9.53,4.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,20,,1.528,Percent of Total Billed Charges,20% of Total Billed Charges,1.91,20,,1.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,20,,1.528,Percent of Total Billed Charges,20% of Total Billed Charges,1.91,20,,1.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,65,,4.952,Percent of Total Billed Charges,65% of Total Billed Charges,6.19,65,,4.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,53.67,
carBAMazepine TAB [200 MG],3000081,CDM,250,RC,,,Outpatient,,,5.77,2.89,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.75,65,,3,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,65,,3,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,53.67,
CARBIDOPA/LEVO TAB [25-100 MG],3000082,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
CARVEDILOL TAB [12.5 MG],3000083,CDM,637,RC,,,Outpatient,,,10.87,5.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,53.67,
CARVEDILOL TAB [25 MG],3000084,CDM,637,RC,,,Outpatient,,,10.87,5.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,53.67,
CARVEDILOL TAB [3.125 MG],3000085,CDM,637,RC,,,Outpatient,,,10.87,5.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,53.67,
CARVEDILOL TAB [6.25 MG],3000086,CDM,637,RC,,,Outpatient,,,10.87,5.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,2.17,20,,1.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,53.67,
CASIRIVIMAB/IMDEVIMAB 600-600 MG/10 ML,3000087,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ceFAZolin INJ [1000 MG] IM,3000088,CDM,636,RC,J0690,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
CEFDINIR CAP [300 MG],3000089,CDM,637,RC,,,Outpatient,,,26.32,13.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.26,20,,4.208,Percent of Total Billed Charges,20% of Total Billed Charges,5.26,20,,4.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.26,20,,4.208,Percent of Total Billed Charges,20% of Total Billed Charges,5.26,20,,4.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.11,65,,13.688,Percent of Total Billed Charges,65% of Total Billed Charges,17.11,65,,13.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.26,53.67,
CEFDINIR SUSP [125 MG/5 ML],3000090,CDM,637,RC,,,Outpatient,,,21.89,10.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,20,,3.504,Percent of Total Billed Charges,20% of Total Billed Charges,4.38,20,,3.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,20,,3.504,Percent of Total Billed Charges,20% of Total Billed Charges,4.38,20,,3.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.23,65,,11.384,Percent of Total Billed Charges,65% of Total Billed Charges,14.23,65,,11.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,53.67,
CEFEPIME [1000 MG] IM,3000091,CDM,636,RC,J0692,HCPCS,Outpatient,,,31.72,15.86,,,,,,Other,Not Seperately Reimbuasble,21.57,68,,17.256,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.34,20,,5.072,Percent of Total Billed Charges,20% of Total Billed Charges,6.34,20,,5.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.34,20,,5.072,Percent of Total Billed Charges,20% of Total Billed Charges,6.34,20,,5.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,80,,20.304,Percent of Total Billed Charges,80% of Total Billed Charges,26.96,85,,21.568,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.34,26.96,
"cefTRIAXone INJ [1000 MG] *IM, IVP*",3000092,CDM,636,RC,J0696,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
"cefTRIAXone [2000 MG] *IM, IVP*",3000093,CDM,636,RC,J0696,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
cefTRIAXone [250 MG] IM,3000094,CDM,636,RC,J0696,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
cefTRIAXone [500 MG] IM,3000095,CDM,636,RC,J0696,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
cefTRIAXone [750 MG] IM,3000096,CDM,250,RC,J0696,HCPCS,Outpatient,,,51.5,25.75,,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,68,,28.016,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,53.67,
CELECOXIB CAP [200 MG],3000097,CDM,637,RC,,,Outpatient,,,39.04,19.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.81,20,,6.248,Percent of Total Billed Charges,20% of Total Billed Charges,7.81,20,,6.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.81,20,,6.248,Percent of Total Billed Charges,20% of Total Billed Charges,7.81,20,,6.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,65,,20.304,Percent of Total Billed Charges,65% of Total Billed Charges,25.38,65,,20.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.81,53.67,
CEPHALEXIN CAP [500 MG],3000098,CDM,637,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
CEPHALEXIN SUSP [250 MG/5 M],3000099,CDM,637,RC,,,Outpatient,,,7.42,3.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,65,,3.856,Percent of Total Billed Charges,65% of Total Billed Charges,4.82,65,,3.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,53.67,
CETIRIZINE TAB [10 MG],3000100,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
chlordiazePOXIDE CAP [25 MG],3000101,CDM,250,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
chlordiazePOXIDE CAP [5 MG],3000102,CDM,250,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
CHLORHEX/ ISOPRP ALC LIQ [118 ML],3000103,CDM,250,RC,,,Outpatient,,,35.95,17.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.19,20,,5.752,Percent of Total Billed Charges,20% of Total Billed Charges,7.19,20,,5.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.19,20,,5.752,Percent of Total Billed Charges,20% of Total Billed Charges,7.19,20,,5.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.37,65,,18.696,Percent of Total Billed Charges,65% of Total Billed Charges,23.37,65,,18.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.19,53.67,
CHLORHEXIDINE GLUCONATE [0.12 %],3000104,CDM,250,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
CHLORTHALIDONE TAB [25 MG],3000105,CDM,637,RC,,,Outpatient,,,6.23,3.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,20,,1,Percent of Total Billed Charges,20% of Total Billed Charges,1.25,20,,1,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,20,,1,Percent of Total Billed Charges,20% of Total Billed Charges,1.25,20,,1,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,65,,3.24,Percent of Total Billed Charges,65% of Total Billed Charges,4.05,65,,3.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,53.67,
CHOLESTYRAMINE PKT [4 GM],3000106,CDM,250,RC,,,Outpatient,,,17.36,8.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,65,,9.024,Percent of Total Billed Charges,65% of Total Billed Charges,11.28,65,,9.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,53.67,
CILOSTAZOL TAB [100 MG],3000107,CDM,637,RC,,,Outpatient,,,11.59,5.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,20,,1.856,Percent of Total Billed Charges,20% of Total Billed Charges,2.32,20,,1.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,20,,1.856,Percent of Total Billed Charges,20% of Total Billed Charges,2.32,20,,1.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,65,,6.024,Percent of Total Billed Charges,65% of Total Billed Charges,7.53,65,,6.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,53.67,
CIPROFLOXACIN TAB [250 MG],3000108,CDM,637,RC,,,Outpatient,,,28.12,14.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.62,20,,4.496,Percent of Total Billed Charges,20% of Total Billed Charges,5.62,20,,4.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.62,20,,4.496,Percent of Total Billed Charges,20% of Total Billed Charges,5.62,20,,4.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.28,65,,14.624,Percent of Total Billed Charges,65% of Total Billed Charges,18.28,65,,14.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.62,53.67,
CIPROFLOXACIN TAB [500 MG],3000109,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
CIPROFLOXACIN/D5W [400 MG/200ML],3000110,CDM,636,RC,J0744,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
CITALOPRAM TAB [20 MG],3000111,CDM,637,RC,,,Outpatient,,,13.91,6.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,20,,2.224,Percent of Total Billed Charges,20% of Total Billed Charges,2.78,20,,2.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,20,,2.224,Percent of Total Billed Charges,20% of Total Billed Charges,2.78,20,,2.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.04,65,,7.232,Percent of Total Billed Charges,65% of Total Billed Charges,9.04,65,,7.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,53.67,
CLARITHROMYCIN TAB [500 MG],3000112,CDM,637,RC,,,Outpatient,,,31,15.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,53.67,
CLINDAMYCIN [600 MG/4ML] IM,3000113,CDM,636,RC,J0736,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
CLINDAMYCIN CAP [150 MG],3000114,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
CLOBETASOL 0.05% CRM [15 GM],3000115,CDM,637,RC,,,Outpatient,,,140.39,70.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.08,20,,22.464,Percent of Total Billed Charges,20% of Total Billed Charges,28.08,20,,22.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.08,20,,22.464,Percent of Total Billed Charges,20% of Total Billed Charges,28.08,20,,22.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.25,65,,73,Percent of Total Billed Charges,65% of Total Billed Charges,91.25,65,,73,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.08,91.25,
clonazePAM TAB [0.5 MG],3000116,CDM,250,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
clonazePAM TAB [1 MG],3000117,CDM,250,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
cloNIDine [0.1 MG/24H] PATCH,3000118,CDM,250,RC,,,Outpatient,,,68.34,34.17,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.67,20,,10.936,Percent of Total Billed Charges,20% of Total Billed Charges,13.67,20,,10.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.67,20,,10.936,Percent of Total Billed Charges,20% of Total Billed Charges,13.67,20,,10.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.42,65,,35.536,Percent of Total Billed Charges,65% of Total Billed Charges,44.42,65,,35.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.67,53.67,
cloNIDine [0.2 MG/24H] PATCH,3000119,CDM,250,RC,,,Outpatient,,,114.9,57.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,20,,18.384,Percent of Total Billed Charges,20% of Total Billed Charges,22.98,20,,18.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,20,,18.384,Percent of Total Billed Charges,20% of Total Billed Charges,22.98,20,,18.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.69,65,,59.752,Percent of Total Billed Charges,65% of Total Billed Charges,74.69,65,,59.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,74.69,
cloNIDine TAB [0.1 MG],3000120,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
cloNIDine TAB [0.2 MG],3000121,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
CLOPIDOGREL TAB [75 MG],3000122,CDM,637,RC,,,Outpatient,,,22.51,11.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,20,,3.6,Percent of Total Billed Charges,20% of Total Billed Charges,4.5,20,,3.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,20,,3.6,Percent of Total Billed Charges,20% of Total Billed Charges,4.5,20,,3.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,65,,11.704,Percent of Total Billed Charges,65% of Total Billed Charges,14.63,65,,11.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,53.67,
CLOTRIMAZ/ BETAMETH CRM [15 GM],3000123,CDM,637,RC,,,Outpatient,,,41.72,20.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.34,20,,6.672,Percent of Total Billed Charges,20% of Total Billed Charges,8.34,20,,6.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.34,20,,6.672,Percent of Total Billed Charges,20% of Total Billed Charges,8.34,20,,6.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.12,65,,21.696,Percent of Total Billed Charges,65% of Total Billed Charges,27.12,65,,21.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.34,53.67,
CLOTRIMAZOLE 1% CRM [15 GM],3000124,CDM,637,RC,,,Outpatient,,,41.1,20.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.22,20,,6.576,Percent of Total Billed Charges,20% of Total Billed Charges,8.22,20,,6.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.22,20,,6.576,Percent of Total Billed Charges,20% of Total Billed Charges,8.22,20,,6.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.72,65,,21.376,Percent of Total Billed Charges,65% of Total Billed Charges,26.72,65,,21.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.22,53.67,
COLCRYS TAB [0.6 MG],3000125,CDM,637,RC,,,Outpatient,,,34.71,17.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,20,,5.552,Percent of Total Billed Charges,20% of Total Billed Charges,6.94,20,,5.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,20,,5.552,Percent of Total Billed Charges,20% of Total Billed Charges,6.94,20,,5.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.56,65,,18.048,Percent of Total Billed Charges,65% of Total Billed Charges,22.56,65,,18.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,53.67,
COLLAGENASE OINT [250 U/GM],3000126,CDM,250,RC,,,Outpatient,,,571.63,285.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.33,20,,91.464,Percent of Total Billed Charges,20% of Total Billed Charges,114.33,20,,91.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.33,20,,91.464,Percent of Total Billed Charges,20% of Total Billed Charges,114.33,20,,91.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.56,65,,297.248,Percent of Total Billed Charges,65% of Total Billed Charges,371.56,65,,297.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,371.56,
COUMADIN CONSULT,3000127,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COUMADIN TAB [1 MG],3000128,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
COUMADIN TAB [2 MG],3000129,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
COUMADIN TAB [2.5 MG],3000130,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
COUMADIN TAB [5 MG],3000131,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
CRANBERRY TAB [450 MG],3000132,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
Crotalidae Polyvalent Immune Fab,3000133,CDM,636,RC,J0840,HCPCS,Outpatient,,,5731.49,2865.75,,3725.47,65,,2980.376,Percent of Total Billed Charges,65% of Total Billed Charges,3897.41,68,,3117.928,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1146.3,20,,917.04,Percent of Total Billed Charges,20% of Total Billed Charges,1146.3,20,,917.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1146.3,20,,917.04,Percent of Total Billed Charges,20% of Total Billed Charges,1146.3,20,,917.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4585.19,80,,3668.152,Percent of Total Billed Charges,80% of Total Billed Charges,4871.77,85,,3897.416,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1146.3,4871.77,
CYCLOBENZAPRINE TAB [10 MG],3000134,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
CYPROHEPTADINE TAB  [4 MG],3000135,CDM,637,RC,,,Outpatient,,,5.51,2.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,20,,0.88,Percent of Total Billed Charges,20% of Total Billed Charges,1.1,20,,0.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,20,,0.88,Percent of Total Billed Charges,20% of Total Billed Charges,1.1,20,,0.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.58,65,,2.864,Percent of Total Billed Charges,65% of Total Billed Charges,3.58,65,,2.864,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,53.67,
DAPTOmycin [500 MG] INJ,3000136,CDM,636,RC,J0878,HCPCS,Outpatient,,,766.32,383.16,,498.11,65,,398.488,Percent of Total Billed Charges,65% of Total Billed Charges,521.1,68,,416.88,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.26,20,,122.608,Percent of Total Billed Charges,20% of Total Billed Charges,153.26,20,,122.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.26,20,,122.608,Percent of Total Billed Charges,20% of Total Billed Charges,153.26,20,,122.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,613.06,80,,490.448,Percent of Total Billed Charges,80% of Total Billed Charges,651.37,85,,521.096,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.26,651.37,
DENOSUMAB [60 MG] INJ,3000137,CDM,636,RC,J0897,HCPCS,Outpatient,,,2291.85,1145.93,,1489.7,65,,1191.76,Percent of Total Billed Charges,65% of Total Billed Charges,1558.46,68,,1246.768,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.37,20,,366.696,Percent of Total Billed Charges,20% of Total Billed Charges,458.37,20,,366.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.37,20,,366.696,Percent of Total Billed Charges,20% of Total Billed Charges,458.37,20,,366.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1833.48,80,,1466.784,Percent of Total Billed Charges,80% of Total Billed Charges,1948.07,85,,1558.456,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.37,1948.07,
DESMOPRESSIN AMP [4 MCG/1ML],3000138,CDM,636,RC,J2597,HCPCS,Outpatient,,,327.03,163.52,,,,,,Other,Not Seperately Reimbuasble,222.38,68,,177.904,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.41,20,,52.328,Percent of Total Billed Charges,20% of Total Billed Charges,65.41,20,,52.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.41,20,,52.328,Percent of Total Billed Charges,20% of Total Billed Charges,65.41,20,,52.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.62,80,,209.296,Percent of Total Billed Charges,80% of Total Billed Charges,277.98,85,,222.384,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.41,277.98,
DEXAMETHASONE [1 MG/1 ML] SOL,3000139,CDM,250,RC,,,Outpatient,,,27.66,13.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.98,65,,14.384,Percent of Total Billed Charges,65% of Total Billed Charges,17.98,65,,14.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,53.67,
DEXAMETHASONE [4 MG] TAB,3000140,CDM,250,RC,,,Outpatient,,,6.23,3.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,20,,1,Percent of Total Billed Charges,20% of Total Billed Charges,1.25,20,,1,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,20,,1,Percent of Total Billed Charges,20% of Total Billed Charges,1.25,20,,1,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,65,,3.24,Percent of Total Billed Charges,65% of Total Billed Charges,4.05,65,,3.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,53.67,
DEXAMETHASONE [6 MG] TAB,3000141,CDM,250,RC,,,Outpatient,,,9.22,4.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,20,,1.472,Percent of Total Billed Charges,20% of Total Billed Charges,1.84,20,,1.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,20,,1.472,Percent of Total Billed Charges,20% of Total Billed Charges,1.84,20,,1.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.99,65,,4.792,Percent of Total Billed Charges,65% of Total Billed Charges,5.99,65,,4.792,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,53.67,
DEXAMETHASONE INJ [10 MG/ML],3000142,CDM,636,RC,J8540,HCPCS,Outpatient,,,34.81,17.41,,,,,,Other,Not Seperately Reimbuasble,23.67,68,,18.936,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.96,20,,5.568,Percent of Total Billed Charges,20% of Total Billed Charges,6.96,20,,5.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.96,20,,5.568,Percent of Total Billed Charges,20% of Total Billed Charges,6.96,20,,5.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.85,80,,22.28,Percent of Total Billed Charges,80% of Total Billed Charges,29.59,85,,23.672,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.96,29.59,
DEXAMETHASONE INJ [4 MG/ML],3000143,CDM,636,RC,J8540,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
DEXMEDETOMIDINE [200 MCG/ 2 ML] SDV,3000144,CDM,636,RC,,,Outpatient,,,53.1,26.55,,,,,,Other,Not Seperately Reimbuasble,36.11,68,,28.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,20,,8.496,Percent of Total Billed Charges,20% of Total Billed Charges,10.62,20,,8.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,20,,8.496,Percent of Total Billed Charges,20% of Total Billed Charges,10.62,20,,8.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.48,80,,33.984,Percent of Total Billed Charges,80% of Total Billed Charges,45.14,85,,36.112,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,45.14,
DEXTROSE 25% INJ SYR [10 ML],3000145,CDM,250,RC,,,Outpatient,,,50.88,25.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,20,,8.144,Percent of Total Billed Charges,20% of Total Billed Charges,10.18,20,,8.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,20,,8.144,Percent of Total Billed Charges,20% of Total Billed Charges,10.18,20,,8.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.07,65,,26.456,Percent of Total Billed Charges,65% of Total Billed Charges,33.07,65,,26.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,53.67,
DEXTROSE 50% INJ SYR [50 ML],3000146,CDM,250,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
DEXTROSE GEL [15 GM],3000147,CDM,250,RC,,,Outpatient,,,20.34,10.17,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.07,20,,3.256,Percent of Total Billed Charges,20% of Total Billed Charges,4.07,20,,3.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.07,20,,3.256,Percent of Total Billed Charges,20% of Total Billed Charges,4.07,20,,3.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.22,65,,10.576,Percent of Total Billed Charges,65% of Total Billed Charges,13.22,65,,10.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.07,53.67,
DIAZEPAM INJ SYR [10 MG/2 ML],3000148,CDM,636,RC,J3360,HCPCS,Outpatient,,,152.13,76.07,,,,,,Other,Not Seperately Reimbuasble,103.45,68,,82.76,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.43,20,,24.344,Percent of Total Billed Charges,20% of Total Billed Charges,30.43,20,,24.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.43,20,,24.344,Percent of Total Billed Charges,20% of Total Billed Charges,30.43,20,,24.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.7,80,,97.36,Percent of Total Billed Charges,80% of Total Billed Charges,129.31,85,,103.448,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.43,129.31,
DIAZEPAM TAB [5 MG],3000149,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
DICYCLOMINE CAP [10 MG],3000150,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
DICYCLOMINE INJ [20 MG/2 ML],3000151,CDM,636,RC,J0500,HCPCS,Outpatient,,,216.92,108.46,,,,,,Other,Not Seperately Reimbuasble,147.51,68,,118.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.38,20,,34.704,Percent of Total Billed Charges,20% of Total Billed Charges,43.38,20,,34.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.38,20,,34.704,Percent of Total Billed Charges,20% of Total Billed Charges,43.38,20,,34.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.54,80,,138.832,Percent of Total Billed Charges,80% of Total Billed Charges,184.38,85,,147.504,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.38,184.38,
DICYCLOMINE TAB [20 MG],3000152,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
DIGOXIN INJ [500 MCG/2 ML],3000153,CDM,636,RC,J1160,HCPCS,Outpatient,,,30.59,15.30,,,,,,Other,Not Seperately Reimbuasble,20.8,68,,16.64,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.12,20,,4.896,Percent of Total Billed Charges,20% of Total Billed Charges,6.12,20,,4.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.12,20,,4.896,Percent of Total Billed Charges,20% of Total Billed Charges,6.12,20,,4.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.47,80,,19.576,Percent of Total Billed Charges,80% of Total Billed Charges,26,85,,20.8,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.12,26,
DIGOXIN ORAL SOL [50 MCG/ML],3000154,CDM,250,RC,,,Outpatient,,,14.42,7.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,53.67,
DIGOXIN TAB [125 MCG],3000155,CDM,637,RC,,,Outpatient,,,8.7,4.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.66,65,,4.528,Percent of Total Billed Charges,65% of Total Billed Charges,5.66,65,,4.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,53.67,
DIGOXIN TAB [250 MCG],3000156,CDM,637,RC,,,Outpatient,,,8.7,4.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,1.74,20,,1.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.66,65,,4.528,Percent of Total Billed Charges,65% of Total Billed Charges,5.66,65,,4.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,53.67,
DILTIAZEM CD (ER) CAP [120 MG],3000157,CDM,637,RC,,,Outpatient,,,6.18,3.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,53.67,
DILTIAZEM CD (ER) CAP [180 MG],3000158,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
DILTIAZEM CD (ER) CAP [240 MG],3000159,CDM,637,RC,,,Outpatient,,,10.61,5.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.12,20,,1.696,Percent of Total Billed Charges,20% of Total Billed Charges,2.12,20,,1.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.12,20,,1.696,Percent of Total Billed Charges,20% of Total Billed Charges,2.12,20,,1.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,65,,5.52,Percent of Total Billed Charges,65% of Total Billed Charges,6.9,65,,5.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.12,53.67,
DILTIAZEM HCL [25 MG/5 ML] INJ,3000160,CDM,637,RC,J3490,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
DILTIAZEM TAB [30 MG],3000161,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
DIPHEN/LID/MYL SUSP [45 ML],3000162,CDM,250,RC,,,Outpatient,,,62.01,31.01,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.31,65,,32.248,Percent of Total Billed Charges,65% of Total Billed Charges,40.31,65,,32.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,53.67,
diphenhydrAMINE [12.5 MG/5 ML] SOL,3000163,CDM,250,RC,,,Outpatient,,,18.44,9.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,20,,2.952,Percent of Total Billed Charges,20% of Total Billed Charges,3.69,20,,2.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,20,,2.952,Percent of Total Billed Charges,20% of Total Billed Charges,3.69,20,,2.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.99,65,,9.592,Percent of Total Billed Charges,65% of Total Billed Charges,11.99,65,,9.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,53.67,
diphenhydrAMINE CAP [25 MG],3000164,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
diphenhydrAMINE CAP [50 MG],3000165,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
diphenhydrAMINE INJ [50 MG/ML],3000166,CDM,636,RC,J1200,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
DIPHENOXY/ ATR [2.5/0.025 MG] TAB,3000167,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
DIVALPROEX DR TAB [250 MG],3000168,CDM,637,RC,,,Outpatient,,,5.56,2.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,20,,0.888,Percent of Total Billed Charges,20% of Total Billed Charges,1.11,20,,0.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,20,,0.888,Percent of Total Billed Charges,20% of Total Billed Charges,1.11,20,,0.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,65,,2.888,Percent of Total Billed Charges,65% of Total Billed Charges,3.61,65,,2.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,53.67,
DIVALPROEX ER TAB [500 MG],3000169,CDM,637,RC,,,Outpatient,,,12.77,6.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.55,20,,2.04,Percent of Total Billed Charges,20% of Total Billed Charges,2.55,20,,2.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.55,20,,2.04,Percent of Total Billed Charges,20% of Total Billed Charges,2.55,20,,2.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.3,65,,6.64,Percent of Total Billed Charges,65% of Total Billed Charges,8.3,65,,6.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.55,53.67,
INF-DOBUTamine [250 MG/250 ML]  PREMIXED,3000170,CDM,636,RC,J1250,HCPCS,Outpatient,,,45.63,22.82,,,,,,Other,Not Seperately Reimbuasble,31.03,68,,24.824,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.13,20,,7.304,Percent of Total Billed Charges,20% of Total Billed Charges,9.13,20,,7.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.13,20,,7.304,Percent of Total Billed Charges,20% of Total Billed Charges,9.13,20,,7.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.5,80,,29.2,Percent of Total Billed Charges,80% of Total Billed Charges,38.79,85,,31.032,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.13,38.79,
DOCUSATE CAP [100 MG],3000171,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
DONEPEZIL TAB [10 MG],3000172,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
DONEPEZIL TAB [5 MG],3000173,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
INF- DOPAMINE [400 MG/250 ML] PREMIX,3000174,CDM,636,RC,J1265,HCPCS,Outpatient,,,67.77,33.89,,,,,,Other,Not Seperately Reimbuasble,46.08,68,,36.864,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.55,20,,10.84,Percent of Total Billed Charges,20% of Total Billed Charges,13.55,20,,10.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.55,20,,10.84,Percent of Total Billed Charges,20% of Total Billed Charges,13.55,20,,10.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.22,80,,43.376,Percent of Total Billed Charges,80% of Total Billed Charges,57.6,85,,46.08,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.55,57.6,
DORZOLAMIDE OPTH [2 %],3000175,CDM,637,RC,,,Outpatient,,,137.61,68.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.52,20,,22.016,Percent of Total Billed Charges,20% of Total Billed Charges,27.52,20,,22.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.52,20,,22.016,Percent of Total Billed Charges,20% of Total Billed Charges,27.52,20,,22.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.45,65,,71.56,Percent of Total Billed Charges,65% of Total Billed Charges,89.45,65,,71.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.52,89.45,
DOXYCYCLINE [100MG] INJ,3000176,CDM,636,RC,J3490,HCPCS,Outpatient,,,146.47,73.24,,,,,,Other,Not Seperately Reimbuasble,99.6,68,,79.68,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.29,20,,23.432,Percent of Total Billed Charges,20% of Total Billed Charges,29.29,20,,23.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.29,20,,23.432,Percent of Total Billed Charges,20% of Total Billed Charges,29.29,20,,23.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.18,80,,93.744,Percent of Total Billed Charges,80% of Total Billed Charges,124.5,85,,99.6,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.29,124.5,
DOXYCYCLINE CAP [100 MG],3000177,CDM,637,RC,,,Outpatient,,,12.67,6.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,20,,2.024,Percent of Total Billed Charges,20% of Total Billed Charges,2.53,20,,2.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,20,,2.024,Percent of Total Billed Charges,20% of Total Billed Charges,2.53,20,,2.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,65,,6.592,Percent of Total Billed Charges,65% of Total Billed Charges,8.24,65,,6.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,53.67,
DULoxetine DR CAP [30 MG],3000178,CDM,637,RC,,,Outpatient,,,40.48,20.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.1,20,,6.48,Percent of Total Billed Charges,20% of Total Billed Charges,8.1,20,,6.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.1,20,,6.48,Percent of Total Billed Charges,20% of Total Billed Charges,8.1,20,,6.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.31,65,,21.048,Percent of Total Billed Charges,65% of Total Billed Charges,26.31,65,,21.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.1,53.67,
DULoxetine DR CAP [60 MG],3000179,CDM,637,RC,,,Outpatient,,,40.48,20.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.1,20,,6.48,Percent of Total Billed Charges,20% of Total Billed Charges,8.1,20,,6.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.1,20,,6.48,Percent of Total Billed Charges,20% of Total Billed Charges,8.1,20,,6.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.31,65,,21.048,Percent of Total Billed Charges,65% of Total Billed Charges,26.31,65,,21.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.1,53.67,
DUTASTERIDE CAP [0.5 MG],3000180,CDM,637,RC,,,Outpatient,,,31.16,15.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.23,20,,4.984,Percent of Total Billed Charges,20% of Total Billed Charges,6.23,20,,4.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.23,20,,4.984,Percent of Total Billed Charges,20% of Total Billed Charges,6.23,20,,4.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.25,65,,16.2,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,65,,16.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.23,53.67,
EARWAX REMOVAL DROPS (DEBROX)  [6.5%],3000181,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
EMOLLIENT/ SKIN CLEANSER CRM [4 OZ],3000182,CDM,637,RC,,,Outpatient,,,17.72,8.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.54,20,,2.832,Percent of Total Billed Charges,20% of Total Billed Charges,3.54,20,,2.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.54,20,,2.832,Percent of Total Billed Charges,20% of Total Billed Charges,3.54,20,,2.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.52,65,,9.216,Percent of Total Billed Charges,65% of Total Billed Charges,11.52,65,,9.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.54,53.67,
ENALAPRILAT [1.25 MG/ML]* IV* INJ,3000183,CDM,636,RC,J3490,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
ENOXAPARIN INJ [100 MG/ML],3000184,CDM,636,RC,J1650,HCPCS,Outpatient,,,83.43,41.72,,,,,,Other,Not Seperately Reimbuasble,56.73,68,,45.384,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.74,80,,53.392,Percent of Total Billed Charges,80% of Total Billed Charges,70.92,85,,56.736,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,70.92,
ENOXAPARIN INJ [120 MG/0.8 ML],3000185,CDM,636,RC,J1650,HCPCS,Outpatient,,,100.12,50.06,,,,,,Other,Not Seperately Reimbuasble,68.08,68,,54.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.02,20,,16.016,Percent of Total Billed Charges,20% of Total Billed Charges,20.02,20,,16.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.02,20,,16.016,Percent of Total Billed Charges,20% of Total Billed Charges,20.02,20,,16.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.1,80,,64.08,Percent of Total Billed Charges,80% of Total Billed Charges,85.1,85,,68.08,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.02,85.1,
ENOXAPARIN INJ [30 MG/0.3 ML],3000186,CDM,636,RC,J1650,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
ENOXAPARIN INJ [40 MG/0.4 ML],3000187,CDM,636,RC,J1650,HCPCS,Outpatient,,,33.37,16.69,,,,,,Other,Not Seperately Reimbuasble,22.69,68,,18.152,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.7,80,,21.36,Percent of Total Billed Charges,80% of Total Billed Charges,28.36,85,,22.688,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,28.36,
ENOXAPARIN INJ [60 MG/0.6 ML],3000188,CDM,636,RC,J1650,HCPCS,Outpatient,,,50.06,25.03,,,,,,Other,Not Seperately Reimbuasble,34.04,68,,27.232,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,20,,8.008,Percent of Total Billed Charges,20% of Total Billed Charges,10.01,20,,8.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,20,,8.008,Percent of Total Billed Charges,20% of Total Billed Charges,10.01,20,,8.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.05,80,,32.04,Percent of Total Billed Charges,80% of Total Billed Charges,42.55,85,,34.04,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,42.55,
ENOXAPARIN INJ [80 MG/0.8 ML],3000189,CDM,636,RC,J1650,HCPCS,Outpatient,,,66.74,33.37,,,,,,Other,Not Seperately Reimbuasble,45.38,68,,36.304,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.35,20,,10.68,Percent of Total Billed Charges,20% of Total Billed Charges,13.35,20,,10.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.35,20,,10.68,Percent of Total Billed Charges,20% of Total Billed Charges,13.35,20,,10.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.39,80,,42.712,Percent of Total Billed Charges,80% of Total Billed Charges,56.73,85,,45.384,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.35,56.73,
EPHEDRINE INJ [50 MG/ML],3000190,CDM,636,RC,J3490,HCPCS,Outpatient,,,244.63,122.32,,,,,,Other,Not Seperately Reimbuasble,166.35,68,,133.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.93,20,,39.144,Percent of Total Billed Charges,20% of Total Billed Charges,48.93,20,,39.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.93,20,,39.144,Percent of Total Billed Charges,20% of Total Billed Charges,48.93,20,,39.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.7,80,,156.56,Percent of Total Billed Charges,80% of Total Billed Charges,207.94,85,,166.352,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.93,207.94,
EPINEPHrine INJ [1MG/ML] AMP,3000191,CDM,636,RC,J0171,HCPCS,Outpatient,,,81.11,40.56,,,,,,Other,Not Seperately Reimbuasble,55.15,68,,44.12,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.89,80,,51.912,Percent of Total Billed Charges,80% of Total Billed Charges,68.94,85,,55.152,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,68.94,
EPINEPHrine INJ SYR [1 MG/10 ML],3000192,CDM,636,RC,J0171,HCPCS,Outpatient,,,48.67,24.34,,,,,,Other,Not Seperately Reimbuasble,33.1,68,,26.48,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.73,20,,7.784,Percent of Total Billed Charges,20% of Total Billed Charges,9.73,20,,7.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.73,20,,7.784,Percent of Total Billed Charges,20% of Total Billed Charges,9.73,20,,7.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.94,80,,31.152,Percent of Total Billed Charges,80% of Total Billed Charges,41.37,85,,33.096,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.73,41.37,
"EPOETIN ALFA INJ [10,000 UNT/ML]",3000193,CDM,636,RC,J0885,HCPCS,Outpatient,,,479,239.50,,,,,,Other,Not Seperately Reimbuasble,325.72,68,,260.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.8,20,,76.64,Percent of Total Billed Charges,20% of Total Billed Charges,95.8,20,,76.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.8,20,,76.64,Percent of Total Billed Charges,20% of Total Billed Charges,95.8,20,,76.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.2,80,,306.56,Percent of Total Billed Charges,80% of Total Billed Charges,407.15,85,,325.72,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.8,407.15,
ERTAPENEM [1000 MG] *IM*,3000194,CDM,636,RC,J1335,HCPCS,Outpatient,,,578.81,289.41,,376.23,65,,300.984,Percent of Total Billed Charges,65% of Total Billed Charges,393.59,68,,314.872,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.76,20,,92.608,Percent of Total Billed Charges,20% of Total Billed Charges,115.76,20,,92.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.76,20,,92.608,Percent of Total Billed Charges,20% of Total Billed Charges,115.76,20,,92.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,463.05,80,,370.44,Percent of Total Billed Charges,80% of Total Billed Charges,491.99,85,,393.592,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.76,491.99,
ERYTHROMYCIN OPTH OINT [0.5 %] [5 MG/G],3000195,CDM,250,RC,,,Outpatient,,,25.6,12.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.12,20,,4.096,Percent of Total Billed Charges,20% of Total Billed Charges,5.12,20,,4.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.12,20,,4.096,Percent of Total Billed Charges,20% of Total Billed Charges,5.12,20,,4.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.64,65,,13.312,Percent of Total Billed Charges,65% of Total Billed Charges,16.64,65,,13.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.12,53.67,
ESCITALOPRAM TAB [10 MG],3000196,CDM,637,RC,,,Outpatient,,,22.56,11.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.51,20,,3.608,Percent of Total Billed Charges,20% of Total Billed Charges,4.51,20,,3.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.51,20,,3.608,Percent of Total Billed Charges,20% of Total Billed Charges,4.51,20,,3.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.66,65,,11.728,Percent of Total Billed Charges,65% of Total Billed Charges,14.66,65,,11.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.51,53.67,
ETHYL CHLORIDE SPR,3000197,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ETOMIDATE INJ [40 MG/20 ML] MDV,3000198,CDM,636,RC,,,Outpatient,,,51.45,25.73,,,,,,Other,Not Seperately Reimbuasble,34.99,68,,27.992,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.29,20,,8.232,Percent of Total Billed Charges,20% of Total Billed Charges,10.29,20,,8.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.29,20,,8.232,Percent of Total Billed Charges,20% of Total Billed Charges,10.29,20,,8.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.16,80,,32.928,Percent of Total Billed Charges,80% of Total Billed Charges,43.73,85,,34.984,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.29,43.73,
EZETIMIBE TAB [10 MG],3000199,CDM,637,RC,,,Outpatient,,,53.2,26.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,20,,8.512,Percent of Total Billed Charges,20% of Total Billed Charges,10.64,20,,8.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,20,,8.512,Percent of Total Billed Charges,20% of Total Billed Charges,10.64,20,,8.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.58,65,,27.664,Percent of Total Billed Charges,65% of Total Billed Charges,34.58,65,,27.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,53.67,
FAMOTIDINE INJ [20 MG/2 ML] *IVP-S*,3000200,CDM,250,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
FAMOTIDINE [20 MG/50 ML] PREMIXED,3000201,CDM,250,RC,,,Outpatient,,,26.73,13.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.35,20,,4.28,Percent of Total Billed Charges,20% of Total Billed Charges,5.35,20,,4.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.35,20,,4.28,Percent of Total Billed Charges,20% of Total Billed Charges,5.35,20,,4.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,65,,13.896,Percent of Total Billed Charges,65% of Total Billed Charges,17.37,65,,13.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.35,53.67,
FAMOTIDINE TAB [20 MG],3000202,CDM,637,RC,,,Outpatient,,,15.6,7.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.12,20,,2.496,Percent of Total Billed Charges,20% of Total Billed Charges,3.12,20,,2.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.12,20,,2.496,Percent of Total Billed Charges,20% of Total Billed Charges,3.12,20,,2.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.14,65,,8.112,Percent of Total Billed Charges,65% of Total Billed Charges,10.14,65,,8.112,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.12,53.67,
FENOFIBRATE [160 MG],3000203,CDM,637,RC,,,Outpatient,,,16.63,8.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.33,20,,2.664,Percent of Total Billed Charges,20% of Total Billed Charges,3.33,20,,2.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.33,20,,2.664,Percent of Total Billed Charges,20% of Total Billed Charges,3.33,20,,2.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.81,65,,8.648,Percent of Total Billed Charges,65% of Total Billed Charges,10.81,65,,8.648,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.33,53.67,
FENOFIBRATE TAB [145 MG],3000204,CDM,637,RC,,,Outpatient,,,5.77,2.89,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.75,65,,3,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,65,,3,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,53.67,
fentaNYL [100 MCG/2 ML] INJ,3000205,CDM,636,RC,J3010,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
FentaNYL [12 MCG/HR] PATCH,3000206,CDM,637,RC,,,Outpatient,,,41.82,20.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.36,20,,6.688,Percent of Total Billed Charges,20% of Total Billed Charges,8.36,20,,6.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.36,20,,6.688,Percent of Total Billed Charges,20% of Total Billed Charges,8.36,20,,6.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.18,65,,21.744,Percent of Total Billed Charges,65% of Total Billed Charges,27.18,65,,21.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.36,53.67,
FentaNYL [25 MCG/HR] PATCH,3000207,CDM,637,RC,,,Outpatient,,,43.83,21.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.77,20,,7.016,Percent of Total Billed Charges,20% of Total Billed Charges,8.77,20,,7.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.77,20,,7.016,Percent of Total Billed Charges,20% of Total Billed Charges,8.77,20,,7.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.49,65,,22.792,Percent of Total Billed Charges,65% of Total Billed Charges,28.49,65,,22.792,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.77,53.67,
FentaNYL [50 MCG/HR] PATCH,3000208,CDM,637,RC,,,Outpatient,,,80.13,40.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.03,20,,12.824,Percent of Total Billed Charges,20% of Total Billed Charges,16.03,20,,12.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.03,20,,12.824,Percent of Total Billed Charges,20% of Total Billed Charges,16.03,20,,12.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.08,65,,41.664,Percent of Total Billed Charges,65% of Total Billed Charges,52.08,65,,41.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.03,53.67,
fentaNYL PAT [100 MCG/HR],3000209,CDM,637,RC,,,Outpatient,,,110.06,55.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.01,20,,17.608,Percent of Total Billed Charges,20% of Total Billed Charges,22.01,20,,17.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.01,20,,17.608,Percent of Total Billed Charges,20% of Total Billed Charges,22.01,20,,17.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.54,65,,57.232,Percent of Total Billed Charges,65% of Total Billed Charges,71.54,65,,57.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.01,71.54,
fentaNYL PAT [75 MCG/HR],3000210,CDM,637,RC,,,Outpatient,,,82.86,41.43,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.57,20,,13.256,Percent of Total Billed Charges,20% of Total Billed Charges,16.57,20,,13.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.57,20,,13.256,Percent of Total Billed Charges,20% of Total Billed Charges,16.57,20,,13.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.86,65,,43.088,Percent of Total Billed Charges,65% of Total Billed Charges,53.86,65,,43.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.57,53.86,
FERROUS SULF LIQ [220 MG/5 ML](IRON 44E),3000211,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
FERROUS SULF TAB [325 (65 Fe) MG],3000212,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
FINASTERIDE TAB [5 MG],3000213,CDM,637,RC,,,Outpatient,,,16.12,8.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,20,,2.576,Percent of Total Billed Charges,20% of Total Billed Charges,3.22,20,,2.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,20,,2.576,Percent of Total Billed Charges,20% of Total Billed Charges,3.22,20,,2.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.48,65,,8.384,Percent of Total Billed Charges,65% of Total Billed Charges,10.48,65,,8.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,53.67,
FLUCONAZOLE [200 MG/100 ML] PREMIX,3000214,CDM,636,RC,J1450,HCPCS,Outpatient,,,50.06,25.03,,,,,,Other,Not Seperately Reimbuasble,34.04,68,,27.232,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,20,,8.008,Percent of Total Billed Charges,20% of Total Billed Charges,10.01,20,,8.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,20,,8.008,Percent of Total Billed Charges,20% of Total Billed Charges,10.01,20,,8.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.05,80,,32.04,Percent of Total Billed Charges,80% of Total Billed Charges,42.55,85,,34.04,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,42.55,
FLUCONAZOLE SUSP [10 MG/ML ],3000215,CDM,250,RC,,,Outpatient,,,26.42,13.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.28,20,,4.224,Percent of Total Billed Charges,20% of Total Billed Charges,5.28,20,,4.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.28,20,,4.224,Percent of Total Billed Charges,20% of Total Billed Charges,5.28,20,,4.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.17,65,,13.736,Percent of Total Billed Charges,65% of Total Billed Charges,17.17,65,,13.736,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.28,53.67,
FLUCONAZOLE TAB [100 MG],3000216,CDM,637,RC,,,Outpatient,,,45.37,22.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.07,20,,7.256,Percent of Total Billed Charges,20% of Total Billed Charges,9.07,20,,7.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.07,20,,7.256,Percent of Total Billed Charges,20% of Total Billed Charges,9.07,20,,7.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.49,65,,23.592,Percent of Total Billed Charges,65% of Total Billed Charges,29.49,65,,23.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.07,53.67,
FLUDROCORTISONE TAB [0.1 MG],3000217,CDM,637,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
FLUMAZENIL INJ [0.5 MG/5 ML],3000218,CDM,636,RC,J3490,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
FLUORESCEIN SOD 1 MG [EYE],3000219,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
FLUoxetine CAP [10 MG],3000220,CDM,637,RC,,,Outpatient,,,12.46,6.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.49,20,,1.992,Percent of Total Billed Charges,20% of Total Billed Charges,2.49,20,,1.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.49,20,,1.992,Percent of Total Billed Charges,20% of Total Billed Charges,2.49,20,,1.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.1,65,,6.48,Percent of Total Billed Charges,65% of Total Billed Charges,8.1,65,,6.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.49,53.67,
FLUoxetine CAP [20 MG],3000221,CDM,637,RC,,,Outpatient,,,12.82,6.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.56,20,,2.048,Percent of Total Billed Charges,20% of Total Billed Charges,2.56,20,,2.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.56,20,,2.048,Percent of Total Billed Charges,20% of Total Billed Charges,2.56,20,,2.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.33,65,,6.664,Percent of Total Billed Charges,65% of Total Billed Charges,8.33,65,,6.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.56,53.67,
FLUSH - SOD CL 0.9 % (SUBCUTANEOUS) 10ML,3000222,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FLUSH SOD CL 0.9%,3000223,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FLUTICASONE PROPIONATE [50 MCG/ACT],3000224,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
FOLIC ACID INJ [50 MG/10 ML] MDV,3000225,CDM,636,RC,J3490,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
FOLIC ACID TAB [1 MG],3000226,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
RT- FORMOTEROL NEB [20 MCG/2 ML],3000227,CDM,250,RC,,,Outpatient,,,53.66,26.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.73,20,,8.584,Percent of Total Billed Charges,20% of Total Billed Charges,10.73,20,,8.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.73,20,,8.584,Percent of Total Billed Charges,20% of Total Billed Charges,10.73,20,,8.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.88,65,,27.904,Percent of Total Billed Charges,65% of Total Billed Charges,34.88,65,,27.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.73,53.67,
FUROSEMIDE INJ [100 MG/10 ML],3000228,CDM,636,RC,J1940,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
FUROSEMIDE INJ [20 MG/2 ML],3000229,CDM,636,RC,J1940,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
FUROSEMIDE INJ [40 MG/4 ML],3000230,CDM,636,RC,J1940,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
FUROSEMIDE TAB [20 MG],3000231,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
FUROSEMIDE TAB [40 MG],3000232,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
G TUBE FLUSH,3000233,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GABAPENTIN CAP [100 MG],3000234,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
GABAPENTIN CAP [300 MG],3000235,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
GABAPENTIN CAP [400 MG],3000236,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
GABAPENTIN TAB [600 MG],3000237,CDM,637,RC,,,Outpatient,,,12.51,6.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,20,,2,Percent of Total Billed Charges,20% of Total Billed Charges,2.5,20,,2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,20,,2,Percent of Total Billed Charges,20% of Total Billed Charges,2.5,20,,2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.13,65,,6.504,Percent of Total Billed Charges,65% of Total Billed Charges,8.13,65,,6.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,53.67,
GABAPENTIN TAB [800 MG],3000238,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
GALANTAMINE TAB  [4 MG],3000239,CDM,637,RC,,,Outpatient,,,21.63,10.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.06,65,,11.248,Percent of Total Billed Charges,65% of Total Billed Charges,14.06,65,,11.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,53.67,
GENTAMICIN INJ [80 MG/2 ML] IM,3000240,CDM,636,RC,J1580,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
GENTAMICIN 0.1% CRM,3000241,CDM,637,RC,,,Outpatient,,,33.94,16.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.79,20,,5.432,Percent of Total Billed Charges,20% of Total Billed Charges,6.79,20,,5.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.79,20,,5.432,Percent of Total Billed Charges,20% of Total Billed Charges,6.79,20,,5.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.06,65,,17.648,Percent of Total Billed Charges,65% of Total Billed Charges,22.06,65,,17.648,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.79,53.67,
GENTAMICIN 0.1% OINT,3000242,CDM,637,RC,,,Outpatient,,,73.03,36.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,20,,11.688,Percent of Total Billed Charges,20% of Total Billed Charges,14.61,20,,11.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,20,,11.688,Percent of Total Billed Charges,20% of Total Billed Charges,14.61,20,,11.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.47,65,,37.976,Percent of Total Billed Charges,65% of Total Billed Charges,47.47,65,,37.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,53.67,
GENTAMICIN OPTH DRP [0.3 %],3000243,CDM,637,RC,,,Outpatient,,,88.27,44.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.65,20,,14.12,Percent of Total Billed Charges,20% of Total Billed Charges,17.65,20,,14.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.65,20,,14.12,Percent of Total Billed Charges,20% of Total Billed Charges,17.65,20,,14.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.38,65,,45.904,Percent of Total Billed Charges,65% of Total Billed Charges,57.38,65,,45.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.65,57.38,
GENTAMICIN SULF OPTH OINT [0.3 %],3000244,CDM,637,RC,,,Outpatient,,,73.03,36.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,20,,11.688,Percent of Total Billed Charges,20% of Total Billed Charges,14.61,20,,11.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,20,,11.688,Percent of Total Billed Charges,20% of Total Billed Charges,14.61,20,,11.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.47,65,,37.976,Percent of Total Billed Charges,65% of Total Billed Charges,47.47,65,,37.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,53.67,
GLIMEPIRIDE TAB [2 MG],3000245,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
GLIMEPIRIDE TAB [4 MG],3000246,CDM,637,RC,,,Outpatient,,,6.28,3.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,20,,1.008,Percent of Total Billed Charges,20% of Total Billed Charges,1.26,20,,1.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,20,,1.008,Percent of Total Billed Charges,20% of Total Billed Charges,1.26,20,,1.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.08,65,,3.264,Percent of Total Billed Charges,65% of Total Billed Charges,4.08,65,,3.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,53.67,
glipiZIDE ER TAB [2.5 MG],3000247,CDM,637,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
glipiZIDE ER TAB [5 MG],3000248,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
glipiZIDE TAB [5 MG],3000249,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
GLUCAGON INJ [1 MG],3000250,CDM,636,RC,J1610,HCPCS,Outpatient,,,636.33,318.17,,413.61,65,,330.888,Percent of Total Billed Charges,65% of Total Billed Charges,432.7,68,,346.16,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.27,20,,101.816,Percent of Total Billed Charges,20% of Total Billed Charges,127.27,20,,101.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.27,20,,101.816,Percent of Total Billed Charges,20% of Total Billed Charges,127.27,20,,101.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,509.06,80,,407.248,Percent of Total Billed Charges,80% of Total Billed Charges,540.88,85,,432.704,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.27,540.88,
GLUCERNA 1.0 kCal (BOLUS),3000251,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLUCERNA 1.0 kCal (TUBE FEEDING),3000252,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLUCERNA 1.5 kCal (BOLUS),3000253,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLUCERNA 1.5 kCal (TUBE FEEDING),3000254,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLYCERIN SUPP ADULT,3000255,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
GLYCERIN SUPP CHILD,3000256,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
GLYCOPYRROLATE [0.2 MG/ ML] SDV,3000257,CDM,636,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
GUAIFEN/ DEXTRO LIQ [200-20 MG/10 ML],3000258,CDM,250,RC,,,Outpatient,,,14.27,7.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,20,,2.28,Percent of Total Billed Charges,20% of Total Billed Charges,2.85,20,,2.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,20,,2.28,Percent of Total Billed Charges,20% of Total Billed Charges,2.85,20,,2.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.28,65,,7.424,Percent of Total Billed Charges,65% of Total Billed Charges,9.28,65,,7.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,53.67,
guaiFENesin ER TAB [600 MG],3000259,CDM,637,RC,,,Outpatient,,,5.2,2.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,20,,0.832,Percent of Total Billed Charges,20% of Total Billed Charges,1.04,20,,0.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,20,,0.832,Percent of Total Billed Charges,20% of Total Billed Charges,1.04,20,,0.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.38,65,,2.704,Percent of Total Billed Charges,65% of Total Billed Charges,3.38,65,,2.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,53.67,
HALOPERIDOL LACTATE INJ [5 MG/ML] SDV,3000260,CDM,636,RC,J1630,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
HALOPERIDOL ORAL LIQ [2 MG/ML],3000261,CDM,637,RC,,,Outpatient,,,9.17,4.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,20,,1.464,Percent of Total Billed Charges,20% of Total Billed Charges,1.83,20,,1.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,20,,1.464,Percent of Total Billed Charges,20% of Total Billed Charges,1.83,20,,1.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,65,,4.768,Percent of Total Billed Charges,65% of Total Billed Charges,5.96,65,,4.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,53.67,
HALOPERIDOL TAB [1 MG],3000262,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
HALOPERIDOL TAB [5 MG],3000263,CDM,637,RC,,,Outpatient,,,5.3,2.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,20,,0.848,Percent of Total Billed Charges,20% of Total Billed Charges,1.06,20,,0.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,20,,0.848,Percent of Total Billed Charges,20% of Total Billed Charges,1.06,20,,0.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,65,,2.76,Percent of Total Billed Charges,65% of Total Billed Charges,3.45,65,,2.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,53.67,
HEMORRHOIDAL CRM - [28 GM],3000264,CDM,250,RC,,,Outpatient,,,14.42,7.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,53.67,
HEMORRHOIDAL SUPP (PREPARATION H),3000265,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
"HEPARIN INJ [5,000 UNT/ML]",3000266,CDM,636,RC,J1644,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
"INF- HEPARIN 25,000/ 0.45% NS PREMIX",3000267,CDM,636,RC,J1644,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
HEPARIN-LOCK-FLUSH [500 UNT/5 ML],3000268,CDM,636,RC,J1642,HCPCS,Outpatient,,,15.86,7.93,,,,,,Other,Not Seperately Reimbuasble,10.78,68,,8.624,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.69,80,,10.152,Percent of Total Billed Charges,80% of Total Billed Charges,13.48,85,,10.784,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,13.48,
HOME SUPPLY BIN # 2,3000269,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
hydrALAZINE INJ [20 MG/ML],3000270,CDM,636,RC,J0360,HCPCS,Outpatient,,,52.17,26.09,,,,,,Other,Not Seperately Reimbuasble,35.48,68,,28.384,Percent of Total Billed Charges,68% of Total Billed Charges,9.75,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.43,20,,8.344,Percent of Total Billed Charges,20% of Total Billed Charges,10.43,20,,8.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.43,20,,8.344,Percent of Total Billed Charges,20% of Total Billed Charges,10.43,20,,8.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.74,80,,33.392,Percent of Total Billed Charges,80% of Total Billed Charges,44.34,85,,35.472,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.75,44.34,
hydrALAZINE TAB [10 MG],3000271,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
hydrALAZINE TAB [25 MG],3000272,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
hydrALAZINE TAB [50 MG],3000273,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
HYDROCHLOROTHIAZIDE CAP [12.5 MG],3000274,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
HYDROCHLOROTHIAZIDE TAB [25 MG],3000275,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
HYDROCOD/ ACET TAB [10-325 MG],3000276,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
HYDROCOD/ ACET TAB [5-325 MG],3000277,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
HYDROCOD/ ACET TAB [7.5-325 MG],3000278,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
HYDROCOD/ACET [7.5-325 MG/15 ML],3000279,CDM,250,RC,,,Outpatient,,,43.57,21.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.71,20,,6.968,Percent of Total Billed Charges,20% of Total Billed Charges,8.71,20,,6.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.71,20,,6.968,Percent of Total Billed Charges,20% of Total Billed Charges,8.71,20,,6.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.32,65,,22.656,Percent of Total Billed Charges,65% of Total Billed Charges,28.32,65,,22.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.71,53.67,
HYDROCODONE/HOMAT [5MG/1.5 MG PER 5ML],3000280,CDM,250,RC,,,Outpatient,,,19.31,9.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,20,,3.088,Percent of Total Billed Charges,20% of Total Billed Charges,3.86,20,,3.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,20,,3.088,Percent of Total Billed Charges,20% of Total Billed Charges,3.86,20,,3.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.55,65,,10.04,Percent of Total Billed Charges,65% of Total Billed Charges,12.55,65,,10.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,53.67,
HYDROCORTISONE [1 %] CRM,3000281,CDM,250,RC,,,Outpatient,,,14.83,7.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,20,,2.376,Percent of Total Billed Charges,20% of Total Billed Charges,2.97,20,,2.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,20,,2.376,Percent of Total Billed Charges,20% of Total Billed Charges,2.97,20,,2.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.64,65,,7.712,Percent of Total Billed Charges,65% of Total Billed Charges,9.64,65,,7.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,53.67,
HYDROCORTISONE [2.5 %] CRM,3000282,CDM,250,RC,,,Outpatient,,,22.66,11.33,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,53.67,
HYDROCORTISONE ACETATE&PRAMOXINE1% - 1%,3000283,CDM,637,RC,,,Outpatient,,,92.49,46.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,20,,14.8,Percent of Total Billed Charges,20% of Total Billed Charges,18.5,20,,14.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,20,,14.8,Percent of Total Billed Charges,20% of Total Billed Charges,18.5,20,,14.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.12,65,,48.096,Percent of Total Billed Charges,65% of Total Billed Charges,60.12,65,,48.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,60.12,
HYDROCORTISONE SUPP [25 MG],3000284,CDM,250,RC,,,Outpatient,,,20.29,10.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,20,,3.248,Percent of Total Billed Charges,20% of Total Billed Charges,4.06,20,,3.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,20,,3.248,Percent of Total Billed Charges,20% of Total Billed Charges,4.06,20,,3.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,65,,10.552,Percent of Total Billed Charges,65% of Total Billed Charges,13.19,65,,10.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,53.67,
HYDROGEN PEROXIDE 3% SOL [236 ML],3000285,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
HYDROMORPHONE [0.5 MG/0.5 ML],3000286,CDM,636,RC,J1171,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
HYDROMORPHONE INJ [1MG/ML],3000287,CDM,636,RC,J1171,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
HYDROMORPHONE INJ [2 MG/ML],3000288,CDM,636,RC,J1171,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
HYDROMORPHONE TAB [2 MG],3000289,CDM,250,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
HYDROXYCHLOROQUINE TAB [200 MG],3000290,CDM,637,RC,,,Outpatient,,,12.1,6.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,20,,1.936,Percent of Total Billed Charges,20% of Total Billed Charges,2.42,20,,1.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,20,,1.936,Percent of Total Billed Charges,20% of Total Billed Charges,2.42,20,,1.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.87,65,,6.296,Percent of Total Billed Charges,65% of Total Billed Charges,7.87,65,,6.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,53.67,
HYDROXYUREA CAP [500 MG],3000291,CDM,637,RC,,,Outpatient,,,5.72,2.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,20,,0.912,Percent of Total Billed Charges,20% of Total Billed Charges,1.14,20,,0.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,20,,0.912,Percent of Total Billed Charges,20% of Total Billed Charges,1.14,20,,0.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.72,65,,2.976,Percent of Total Billed Charges,65% of Total Billed Charges,3.72,65,,2.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,53.67,
hydrOXYzine HCL TAB [25 MG],3000292,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
hydrOXYzine INJ [25 MG/ML] *IM*,3000293,CDM,636,RC,J3410,HCPCS,Outpatient,,,112.17,56.09,,,,,,Other,Not Seperately Reimbuasble,76.28,68,,61.024,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.43,20,,17.944,Percent of Total Billed Charges,20% of Total Billed Charges,22.43,20,,17.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.43,20,,17.944,Percent of Total Billed Charges,20% of Total Billed Charges,22.43,20,,17.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.74,80,,71.792,Percent of Total Billed Charges,80% of Total Billed Charges,95.34,85,,76.272,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.43,95.34,
HYOSCYAMINE SL TAB [0.125 MG],3000294,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
IBUPROFEN LIQ [200 MG/10 ML],3000295,CDM,637,RC,,,Outpatient,,,7.47,3.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.49,20,,1.192,Percent of Total Billed Charges,20% of Total Billed Charges,1.49,20,,1.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.49,20,,1.192,Percent of Total Billed Charges,20% of Total Billed Charges,1.49,20,,1.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.86,65,,3.888,Percent of Total Billed Charges,65% of Total Billed Charges,4.86,65,,3.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.49,53.67,
IBUPROFEN TAB [400 MG],3000296,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
IBUPROFEN TAB [600 MG],3000297,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
IBUPROFEN TAB [800 MG],3000298,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
IMIPENEM/CILAS [250 MG] INJ,3000299,CDM,636,RC,J0743,HCPCS,Outpatient,,,27.76,13.88,,,,,,Other,Not Seperately Reimbuasble,18.88,68,,15.104,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.55,20,,4.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.21,80,,17.768,Percent of Total Billed Charges,80% of Total Billed Charges,23.6,85,,18.88,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,23.6,
IMIPENEM/CILAS [500 MG] INJ,3000300,CDM,636,RC,J0743,HCPCS,Outpatient,,,181.64,90.82,,,,,,Other,Not Seperately Reimbuasble,123.52,68,,98.816,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.33,20,,29.064,Percent of Total Billed Charges,20% of Total Billed Charges,36.33,20,,29.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.33,20,,29.064,Percent of Total Billed Charges,20% of Total Billed Charges,36.33,20,,29.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.31,80,,116.248,Percent of Total Billed Charges,80% of Total Billed Charges,154.39,85,,123.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.33,154.39,
INDOMETHACIN CAP [25 MG],3000301,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
INS - GLARGINE [100 UNITS/ML],3000302,CDM,637,RC,J1815,HCPCS,Outpatient,,,2.47,1.24,,1.61,65,,1.288,Percent of Total Billed Charges,65% of Total Billed Charges,1.68,68,,1.344,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,20,,0.392,Percent of Total Billed Charges,20% of Total Billed Charges,0.49,20,,0.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,20,,0.392,Percent of Total Billed Charges,20% of Total Billed Charges,0.49,20,,0.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.61,65,,1.288,Percent of Total Billed Charges,65% of Total Billed Charges,1.61,65,,1.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,53.67,
INS - LISPRO [100 UNITS/ML],3000303,CDM,637,RC,J1815,HCPCS,Outpatient,,,6.8,3.40,,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,4.62,68,,3.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,53.67,
INS- NPH HUMAN INJ [100 UNIT/ML],3000304,CDM,636,RC,J1815,HCPCS,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,2.31,68,,1.848,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.72,80,,2.176,Percent of Total Billed Charges,80% of Total Billed Charges,2.89,85,,2.312,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,2.89,
INS- REG HUMAN INJ [100 UNIT/ML],3000305,CDM,636,RC,J1815,HCPCS,Outpatient,,,3.4,1.70,,,,,,Other,Not Seperately Reimbuasble,2.31,68,,1.848,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,0.68,20,,0.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.72,80,,2.176,Percent of Total Billed Charges,80% of Total Billed Charges,2.89,85,,2.312,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,2.89,
IRON SUCROSE INJ (200MG/10ML] SDV,3000306,CDM,636,RC,J1756,HCPCS,Outpatient,,,494.4,247.20,,,,,,Other,Not Seperately Reimbuasble,336.19,68,,268.952,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.88,20,,79.104,Percent of Total Billed Charges,20% of Total Billed Charges,98.88,20,,79.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.88,20,,79.104,Percent of Total Billed Charges,20% of Total Billed Charges,98.88,20,,79.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395.52,80,,316.416,Percent of Total Billed Charges,80% of Total Billed Charges,420.24,85,,336.192,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.88,420.24,
ISOSORBIDE DINITRATE TAB [20 MG],3000307,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ISOSORBIDE MONO ER TAB [30 MG],3000308,CDM,637,RC,,,Outpatient,,,8.55,4.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,20,,1.368,Percent of Total Billed Charges,20% of Total Billed Charges,1.71,20,,1.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,20,,1.368,Percent of Total Billed Charges,20% of Total Billed Charges,1.71,20,,1.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,65,,4.448,Percent of Total Billed Charges,65% of Total Billed Charges,5.56,65,,4.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,53.67,
ISOSORBIDE MONO ER TAB [60 MG],3000309,CDM,637,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
IVF- (NACL 0.45%) [1000 ML],3000310,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IVF- (NACL 0.9%) [100 ML],3000311,CDM,258,RC,,,Outpatient,,,55.62,27.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,53.67,
IVF- (NACL 0.9%) [1000 ML],3000312,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IVF- (NACL 0.9%) [250 ML],3000313,CDM,258,RC,,,Outpatient,,,55.62,27.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,53.67,
IVF- (NACL 0.9%) [50 ML],3000314,CDM,258,RC,,,Outpatient,,,27.66,13.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.98,65,,14.384,Percent of Total Billed Charges,65% of Total Billed Charges,17.98,65,,14.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,53.67,
IVF- (NACL 0.9%) [500 ML],3000315,CDM,258,RC,,,Outpatient,,,64.89,32.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,53.67,
IVF- (NACL 3%) [500 ML],3000316,CDM,250,RC,,,Outpatient,,,64.89,32.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,53.67,
IVF- DEX 5%/ 0.45% SOD CL [1000 ML],3000317,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IVF- DEX 5%/ 0.45% SOD CL [500 ML],3000318,CDM,258,RC,,,Outpatient,,,64.89,32.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,53.67,
IVF- DEX 5%/ 0.9% SOD CL [1000 ML],3000319,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IVF- DEXTROSE 10% [500 ML],3000320,CDM,258,RC,,,Outpatient,,,64.89,32.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,53.67,
IVF- DEXTROSE 10% [50 mL],3000321,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IVF- DEXTROSE 5% [100 ML],3000322,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IVF- DEXTROSE 5% [1000 ML],3000323,CDM,258,RC,,,Outpatient,,,26.88,13.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.47,65,,13.976,Percent of Total Billed Charges,65% of Total Billed Charges,17.47,65,,13.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,53.67,
IVF- DEXTROSE 5% [250 ML],3000324,CDM,258,RC,,,Outpatient,,,55.62,27.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,53.67,
IVF- LACTATED RINGERS [1000 ML],3000325,CDM,258,RC,J7120,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
IVF- POT 20 mEq (NACL 0.9%) [1000 ML],3000326,CDM,636,RC,J3480,HCPCS,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,46.23,68,,36.984,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.38,80,,43.504,Percent of Total Billed Charges,80% of Total Billed Charges,57.78,85,,46.224,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,57.78,
IVF- POT 20mEqDEX 5%/NACL 0.45 %1000 ML,3000327,CDM,636,RC,J3480,HCPCS,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,46.23,68,,36.984,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.38,80,,43.504,Percent of Total Billed Charges,80% of Total Billed Charges,57.78,85,,46.224,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,57.78,
IVF- POT 40 mEq (NACL 0.9%) [1000 ML],3000328,CDM,636,RC,J3480,HCPCS,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,46.23,68,,36.984,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.38,80,,43.504,Percent of Total Billed Charges,80% of Total Billed Charges,57.78,85,,46.224,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,57.78,
IVF- POT CL [10 mEq/100 ML],3000329,CDM,636,RC,J3480,HCPCS,Outpatient,,,55.62,27.81,,,,,,Other,Not Seperately Reimbuasble,37.82,68,,30.256,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.5,80,,35.6,Percent of Total Billed Charges,80% of Total Billed Charges,47.28,85,,37.824,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,47.28,
JEVITY 1.2 kCal (BOLUS),3000330,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KETAMINE INJ [500 MG/10 ML],3000331,CDM,636,RC,J3490,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
KETOCONAZOLE 2% CRM - [15 GM],3000332,CDM,637,RC,,,Outpatient,,,45.11,22.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.02,20,,7.216,Percent of Total Billed Charges,20% of Total Billed Charges,9.02,20,,7.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.02,20,,7.216,Percent of Total Billed Charges,20% of Total Billed Charges,9.02,20,,7.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.32,65,,23.456,Percent of Total Billed Charges,65% of Total Billed Charges,29.32,65,,23.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.02,53.67,
KETOCONAZOLE 2% SHM,3000333,CDM,637,RC,,,Outpatient,,,143.07,71.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.61,20,,22.888,Percent of Total Billed Charges,20% of Total Billed Charges,28.61,20,,22.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.61,20,,22.888,Percent of Total Billed Charges,20% of Total Billed Charges,28.61,20,,22.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93,65,,74.4,Percent of Total Billed Charges,65% of Total Billed Charges,93,65,,74.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.61,93,
KETOROLAC INJ [30 MG/ML] *IV/IM*,3000334,CDM,636,RC,J1885,HCPCS,Outpatient,,,31.98,15.99,,,,,,Other,Not Seperately Reimbuasble,21.75,68,,17.4,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.58,80,,20.464,Percent of Total Billed Charges,80% of Total Billed Charges,27.18,85,,21.744,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,27.18,
KETOROLAC INJ [60 MG/2 ML] *IM*,3000335,CDM,636,RC,J1885,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
KY JELLY [2 OZ],3000336,CDM,637,RC,,,Outpatient,,,12.05,6.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.41,20,,1.928,Percent of Total Billed Charges,20% of Total Billed Charges,2.41,20,,1.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.41,20,,1.928,Percent of Total Billed Charges,20% of Total Billed Charges,2.41,20,,1.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.83,65,,6.264,Percent of Total Billed Charges,65% of Total Billed Charges,7.83,65,,6.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.41,53.67,
LABETALOL [100 MG/20 ML] INJ MDV,3000337,CDM,636,RC,J1920,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
LABETALOL TAB [100 MG],3000338,CDM,637,RC,,,Outpatient,,,11.79,5.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,20,,1.888,Percent of Total Billed Charges,20% of Total Billed Charges,2.36,20,,1.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,20,,1.888,Percent of Total Billed Charges,20% of Total Billed Charges,2.36,20,,1.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.66,65,,6.128,Percent of Total Billed Charges,65% of Total Billed Charges,7.66,65,,6.128,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,53.67,
LACTOBACILLUS CAP,3000339,CDM,250,RC,,,Outpatient,,,5.87,2.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,20,,0.936,Percent of Total Billed Charges,20% of Total Billed Charges,1.17,20,,0.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,20,,0.936,Percent of Total Billed Charges,20% of Total Billed Charges,1.17,20,,0.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.82,65,,3.056,Percent of Total Billed Charges,65% of Total Billed Charges,3.82,65,,3.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,53.67,
LACTULOSE LIQ [10 GM/15 ML] UD,3000340,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
lamoTRIgine TAB [100 MG],3000341,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LANTISEPTIC OINT [4.5 OZ],3000342,CDM,250,RC,,,Outpatient,,,7.42,3.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,65,,3.856,Percent of Total Billed Charges,65% of Total Billed Charges,4.82,65,,3.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,53.67,
LATANOPROST [0.005 %] OPTH DRP,3000343,CDM,637,RC,,,Outpatient,,,195.7,97.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,127.21,
LEVETIRACETAM [500 MG/5ML] INJ,3000344,CDM,250,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
levETIRAcetam SUSP [500 MG/5 ML],3000345,CDM,250,RC,,,Outpatient,,,15.6,7.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.12,20,,2.496,Percent of Total Billed Charges,20% of Total Billed Charges,3.12,20,,2.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.12,20,,2.496,Percent of Total Billed Charges,20% of Total Billed Charges,3.12,20,,2.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.14,65,,8.112,Percent of Total Billed Charges,65% of Total Billed Charges,10.14,65,,8.112,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.12,53.67,
levETIRAcetam TAB [500 MG],3000346,CDM,637,RC,,,Outpatient,,,16.33,8.17,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.27,20,,2.616,Percent of Total Billed Charges,20% of Total Billed Charges,3.27,20,,2.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.27,20,,2.616,Percent of Total Billed Charges,20% of Total Billed Charges,3.27,20,,2.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.61,65,,8.488,Percent of Total Billed Charges,65% of Total Billed Charges,10.61,65,,8.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.27,53.67,
LEVOFLOXACIN TAB [250 MG],3000347,CDM,637,RC,,,Outpatient,,,75.86,37.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.17,20,,12.136,Percent of Total Billed Charges,20% of Total Billed Charges,15.17,20,,12.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.17,20,,12.136,Percent of Total Billed Charges,20% of Total Billed Charges,15.17,20,,12.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.31,65,,39.448,Percent of Total Billed Charges,65% of Total Billed Charges,49.31,65,,39.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.17,53.67,
LEVOFLOXACIN TAB [500 MG],3000348,CDM,637,RC,,,Outpatient,,,86.62,43.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.32,20,,13.856,Percent of Total Billed Charges,20% of Total Billed Charges,17.32,20,,13.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.32,20,,13.856,Percent of Total Billed Charges,20% of Total Billed Charges,17.32,20,,13.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.3,65,,45.04,Percent of Total Billed Charges,65% of Total Billed Charges,56.3,65,,45.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.32,56.3,
LEVOFLOXACIN TAB [750 MG],3000349,CDM,637,RC,,,Outpatient,,,126.79,63.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.36,20,,20.288,Percent of Total Billed Charges,20% of Total Billed Charges,25.36,20,,20.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.36,20,,20.288,Percent of Total Billed Charges,20% of Total Billed Charges,25.36,20,,20.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.41,65,,65.928,Percent of Total Billed Charges,65% of Total Billed Charges,82.41,65,,65.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.36,82.41,
LEVOFLOXACIN/D5W [250 MG/50 ML] PREMIXED,3000350,CDM,636,RC,J1956,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
LEVOFLOXACIN/D5W [500 MG/100ML] PREMIXED,3000351,CDM,250,RC,J1956,HCPCS,Outpatient,,,76.68,38.34,,49.84,65,,39.872,Percent of Total Billed Charges,65% of Total Billed Charges,52.14,68,,41.712,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.34,20,,12.272,Percent of Total Billed Charges,20% of Total Billed Charges,15.34,20,,12.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.34,20,,12.272,Percent of Total Billed Charges,20% of Total Billed Charges,15.34,20,,12.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.84,65,,39.872,Percent of Total Billed Charges,65% of Total Billed Charges,49.84,65,,39.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.34,53.67,
LEVOFLOXACIN/D5W [750 MG/150 ML]PREMIXED,3000352,CDM,636,RC,J1956,HCPCS,Outpatient,,,72.31,36.16,,,,,,Other,Not Seperately Reimbuasble,49.17,68,,39.336,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.85,80,,46.28,Percent of Total Billed Charges,80% of Total Billed Charges,61.46,85,,49.168,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,61.46,
LEVOTHYROXINE TAB  [112 MCG],3000353,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LEVOTHYROXINE TAB [100 MCG],3000354,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LEVOTHYROXINE TAB [125 MCG],3000355,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LEVOTHYROXINE TAB [25 MCG],3000356,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LEVOTHYROXINE TAB [50 MCG],3000357,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LEVOTHYROXINE TAB [75 MCG],3000358,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LEVOTHYROXINE TAB [88 MCG],3000359,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LIDOCAINE [1%]/EPINEPHRINE INJ MDV,3000360,CDM,250,RC,J2004,HCPCS,Outpatient,,,5.15,2.58,,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LIDOCAINE [2%]/EPINEPHRINE INJ MDV,3000361,CDM,636,RC,J2004,HCPCS,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,80,,3.296,Percent of Total Billed Charges,80% of Total Billed Charges,4.38,85,,3.504,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,4.38,
LIDOCAINE [4 %] - 30 GM,3000362,CDM,636,RC,,,Outpatient,,,43.26,21.63,,,,,,Other,Not Seperately Reimbuasble,29.42,68,,23.536,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,20,,6.92,Percent of Total Billed Charges,20% of Total Billed Charges,8.65,20,,6.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,20,,6.92,Percent of Total Billed Charges,20% of Total Billed Charges,8.65,20,,6.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,80,,27.688,Percent of Total Billed Charges,80% of Total Billed Charges,36.77,85,,29.416,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,36.77,
LIDOCAINE TOPICAL CREAM [4 %] - 5 GM,3000363,CDM,636,RC,,,Outpatient,,,10.82,5.41,,,,,,Other,Not Seperately Reimbuasble,7.36,68,,5.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.66,80,,6.928,Percent of Total Billed Charges,80% of Total Billed Charges,9.2,85,,7.36,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,9.2,
LIDOCAINE [5 %] PATCH,3000364,CDM,637,RC,,,Outpatient,,,19.31,9.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,20,,3.088,Percent of Total Billed Charges,20% of Total Billed Charges,3.86,20,,3.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,20,,3.088,Percent of Total Billed Charges,20% of Total Billed Charges,3.86,20,,3.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.55,65,,10.04,Percent of Total Billed Charges,65% of Total Billed Charges,12.55,65,,10.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,53.67,
LIDOCAINE 1% [500 MG/50 ML] INJ MDV,3000365,CDM,636,RC,J2003,HCPCS,Outpatient,,,27.04,13.52,,,,,,Other,Not Seperately Reimbuasble,18.39,68,,14.712,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.41,20,,4.328,Percent of Total Billed Charges,20% of Total Billed Charges,5.41,20,,4.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.41,20,,4.328,Percent of Total Billed Charges,20% of Total Billed Charges,5.41,20,,4.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,80,,17.304,Percent of Total Billed Charges,80% of Total Billed Charges,22.98,85,,18.384,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.41,22.98,
LIDOCAINE 2 % PF,3000366,CDM,250,RC,,,Outpatient,,,6.75,3.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,20,,1.08,Percent of Total Billed Charges,20% of Total Billed Charges,1.35,20,,1.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,20,,1.08,Percent of Total Billed Charges,20% of Total Billed Charges,1.35,20,,1.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.39,65,,3.512,Percent of Total Billed Charges,65% of Total Billed Charges,4.39,65,,3.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,53.67,
LIDOCAINE 2% [200 MG/10 ML] INJ MDV,3000367,CDM,636,RC,J2003,HCPCS,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,80,,3.296,Percent of Total Billed Charges,80% of Total Billed Charges,4.38,85,,3.504,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,4.38,
LIDOCAINE INJ SYR [100 MG/5 ML],3000368,CDM,636,RC,J2001,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
LIDOCAINE VISC 2%,3000369,CDM,637,RC,,,Outpatient,,,5.56,2.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,20,,0.888,Percent of Total Billed Charges,20% of Total Billed Charges,1.11,20,,0.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,20,,0.888,Percent of Total Billed Charges,20% of Total Billed Charges,1.11,20,,0.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,65,,2.888,Percent of Total Billed Charges,65% of Total Billed Charges,3.61,65,,2.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,53.67,
LINEZOLID/D5W PREMIX [600 MG/300 ML],3000370,CDM,636,RC,J2020,HCPCS,Outpatient,,,26.37,13.19,,,,,,Other,Not Seperately Reimbuasble,17.93,68,,14.344,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,5.27,20,,4.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,80,,16.88,Percent of Total Billed Charges,80% of Total Billed Charges,22.41,85,,17.928,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,22.41,
LISINOPRIL TAB [10 MG],3000371,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LISINOPRIL TAB [20 MG],3000372,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LISINOPRIL TAB [40 MG],3000373,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LISINOPRIL TAB [5 MG],3000374,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LITHIUM CARBONATE CAP [150 MG],3000375,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LOPERAMIDE HCL CAP [2 MG],3000376,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LORATADINE LIQ [5 MG/5 ML],3000377,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LORATADINE TAB [10 MG],3000378,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
LORazepam INJ [2 MG/ML],3000379,CDM,636,RC,J2060,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
LORazepam TAB [0.5 MG],3000380,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
LORazepam TAB [1 MG],3000381,CDM,637,RC,,,Outpatient,,,8.14,4.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.29,65,,4.232,Percent of Total Billed Charges,65% of Total Billed Charges,5.29,65,,4.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,53.67,
LOSARTAN  TAB [100 MG],3000382,CDM,637,RC,,,Outpatient,,,15.86,7.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,3.17,20,,2.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.31,65,,8.248,Percent of Total Billed Charges,65% of Total Billed Charges,10.31,65,,8.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,53.67,
LOSARTAN TAB [25 MG],3000383,CDM,637,RC,,,Outpatient,,,8.65,4.33,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,20,,1.384,Percent of Total Billed Charges,20% of Total Billed Charges,1.73,20,,1.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,20,,1.384,Percent of Total Billed Charges,20% of Total Billed Charges,1.73,20,,1.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.62,65,,4.496,Percent of Total Billed Charges,65% of Total Billed Charges,5.62,65,,4.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,53.67,
LOSARTAN TAB [50 MG],3000384,CDM,637,RC,,,Outpatient,,,11.59,5.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,20,,1.856,Percent of Total Billed Charges,20% of Total Billed Charges,2.32,20,,1.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,20,,1.856,Percent of Total Billed Charges,20% of Total Billed Charges,2.32,20,,1.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,65,,6.024,Percent of Total Billed Charges,65% of Total Billed Charges,7.53,65,,6.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,53.67,
LUBRICANT EYE DROPS 0.5% OPTH  [0.4  ML],3000385,CDM,250,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
MAG HYD/ AL HYD/ SIM SUSP [30ML],3000386,CDM,637,RC,,,Outpatient,,,19.57,9.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.72,65,,10.176,Percent of Total Billed Charges,65% of Total Billed Charges,12.72,65,,10.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,53.67,
MAGNESIUM CITRATE SOL [296 ML],3000387,CDM,637,RC,,,Outpatient,,,10.82,5.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.03,65,,5.624,Percent of Total Billed Charges,65% of Total Billed Charges,7.03,65,,5.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,53.67,
MAGNESIUM HYDROXIDE  [2400 MG] SOL,3000388,CDM,637,RC,,,Outpatient,,,12.1,6.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,20,,1.936,Percent of Total Billed Charges,20% of Total Billed Charges,2.42,20,,1.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,20,,1.936,Percent of Total Billed Charges,20% of Total Billed Charges,2.42,20,,1.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.87,65,,6.296,Percent of Total Billed Charges,65% of Total Billed Charges,7.87,65,,6.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,53.67,
MAGNESIUM OXIDE TAB [400 MG],3000389,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
MAGNESIUM SULF INJ [1 GM/2 ML],3000390,CDM,636,RC,J3475,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
MAGNESIUM SULFATE  [2 GM/50 ML] PREMIX,3000391,CDM,250,RC,,,Outpatient,,,81.11,40.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,16.22,20,,12.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.72,65,,42.176,Percent of Total Billed Charges,65% of Total Billed Charges,52.72,65,,42.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,53.67,
MECLIZINE TAB [12.5 MG],3000392,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
MedroxyPROGESTone TAB [10 MG],3000393,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
MEGESTROL SUSP [400 MG/10 ML],3000394,CDM,637,RC,J3490,HCPCS,Outpatient,,,23.33,11.67,,15.16,65,,12.128,Percent of Total Billed Charges,65% of Total Billed Charges,15.86,68,,12.688,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.67,20,,3.736,Percent of Total Billed Charges,20% of Total Billed Charges,4.67,20,,3.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.67,20,,3.736,Percent of Total Billed Charges,20% of Total Billed Charges,4.67,20,,3.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.16,65,,12.128,Percent of Total Billed Charges,65% of Total Billed Charges,15.16,65,,12.128,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.67,53.67,
MEGESTROL TAB [40 MG],3000395,CDM,637,RC,J3490,HCPCS,Outpatient,,,7.06,3.53,,4.59,65,,3.672,Percent of Total Billed Charges,65% of Total Billed Charges,4.8,68,,3.84,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.41,20,,1.128,Percent of Total Billed Charges,20% of Total Billed Charges,1.41,20,,1.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.41,20,,1.128,Percent of Total Billed Charges,20% of Total Billed Charges,1.41,20,,1.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.59,65,,3.672,Percent of Total Billed Charges,65% of Total Billed Charges,4.59,65,,3.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.41,53.67,
MELATONIN TAB [3 MG],3000396,CDM,637,RC,J3490,HCPCS,Outpatient,,,5.15,2.58,,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
MELOXICAM TAB [15 MG],3000397,CDM,637,RC,J3490,HCPCS,Outpatient,,,24.05,12.03,,15.63,65,,12.504,Percent of Total Billed Charges,65% of Total Billed Charges,16.35,68,,13.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.81,20,,3.848,Percent of Total Billed Charges,20% of Total Billed Charges,4.81,20,,3.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.81,20,,3.848,Percent of Total Billed Charges,20% of Total Billed Charges,4.81,20,,3.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.63,65,,12.504,Percent of Total Billed Charges,65% of Total Billed Charges,15.63,65,,12.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.81,53.67,
MELOXICAM TAB [7.5 MG],3000398,CDM,637,RC,J3490,HCPCS,Outpatient,,,15.97,7.99,,10.38,65,,8.304,Percent of Total Billed Charges,65% of Total Billed Charges,10.86,68,,8.688,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.19,20,,2.552,Percent of Total Billed Charges,20% of Total Billed Charges,3.19,20,,2.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.19,20,,2.552,Percent of Total Billed Charges,20% of Total Billed Charges,3.19,20,,2.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.38,65,,8.304,Percent of Total Billed Charges,65% of Total Billed Charges,10.38,65,,8.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.19,53.67,
MEMANTINE TAB [5 MG],3000399,CDM,637,RC,J3490,HCPCS,Outpatient,,,5.15,2.58,,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
MENTHOL [0.1%]/ZINC OXIDE [20.0%],3000400,CDM,271,RC,,,Outpatient,,,47.07,23.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.41,20,,7.528,Percent of Total Billed Charges,20% of Total Billed Charges,9.41,20,,7.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.41,20,,7.528,Percent of Total Billed Charges,20% of Total Billed Charges,9.41,20,,7.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.6,65,,24.48,Percent of Total Billed Charges,65% of Total Billed Charges,30.6,65,,24.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.41,53.67,
MEROPENEM INJ [1000 MG] SDV,3000401,CDM,636,RC,J2185,HCPCS,Outpatient,,,64.89,32.45,,,,,,Other,Not Seperately Reimbuasble,44.13,68,,35.304,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.91,80,,41.528,Percent of Total Billed Charges,80% of Total Billed Charges,55.16,85,,44.128,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,55.16,
MEROPENEM INJ [500 MG] SDV,3000402,CDM,250,RC,,,Outpatient,,,81.89,40.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.38,20,,13.104,Percent of Total Billed Charges,20% of Total Billed Charges,16.38,20,,13.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.38,20,,13.104,Percent of Total Billed Charges,20% of Total Billed Charges,16.38,20,,13.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.23,65,,42.584,Percent of Total Billed Charges,65% of Total Billed Charges,53.23,65,,42.584,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.38,53.67,
METCL/LID/MAG AL - [45 ML] SUSP,3000403,CDM,637,RC,,,Outpatient,,,38.94,19.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,7.79,20,,6.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.31,65,,20.248,Percent of Total Billed Charges,65% of Total Billed Charges,25.31,65,,20.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,53.67,
metFORMIN TAB [1000 MG],3000404,CDM,637,RC,J3490,HCPCS,Outpatient,,,5.15,2.58,,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
metFORMIN TAB [500 MG],3000405,CDM,637,RC,J3490,HCPCS,Outpatient,,,5.15,2.58,,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
METHADONE TAB [10 MG],3000406,CDM,637,RC,J3490,HCPCS,Outpatient,,,7.98,3.99,,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.43,68,,4.344,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
METHIMAZOLE TAB [5 MG],3000407,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
METHOCARBAMOL TAB [500 MG],3000408,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
METHOTREXATE TAB [2.5 MG],3000409,CDM,636,RC,J8610,HCPCS,Outpatient,,,32.14,16.07,,,,,,Other,Not Seperately Reimbuasble,21.86,68,,17.488,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.43,20,,5.144,Percent of Total Billed Charges,20% of Total Billed Charges,6.43,20,,5.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.43,20,,5.144,Percent of Total Billed Charges,20% of Total Billed Charges,6.43,20,,5.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.71,80,,20.568,Percent of Total Billed Charges,80% of Total Billed Charges,27.32,85,,21.856,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.43,27.32,
METHYLCELLULOSE TAB [500 MG],3000410,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
METHYLPREDNISOLONE [4 MG] TAB,3000411,CDM,636,RC,,,Outpatient,,,8.5,4.25,,,,,,Other,Not Seperately Reimbuasble,5.78,68,,4.624,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,20,,1.36,Percent of Total Billed Charges,20% of Total Billed Charges,1.7,20,,1.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,20,,1.36,Percent of Total Billed Charges,20% of Total Billed Charges,1.7,20,,1.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,80,,5.44,Percent of Total Billed Charges,80% of Total Billed Charges,7.23,85,,5.784,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,7.23,
METHYLPREDNISOLONE INJ [125MG],3000412,CDM,636,RC,J2919,HCPCS,Outpatient,,,53.92,26.96,,,,,,Other,Not Seperately Reimbuasble,36.67,68,,29.336,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.78,20,,8.624,Percent of Total Billed Charges,20% of Total Billed Charges,10.78,20,,8.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.78,20,,8.624,Percent of Total Billed Charges,20% of Total Billed Charges,10.78,20,,8.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.14,80,,34.512,Percent of Total Billed Charges,80% of Total Billed Charges,45.83,85,,36.664,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.78,45.83,
METHYLPREDNISOLONE INJ [40 MG],3000413,CDM,636,RC,J2919,HCPCS,Outpatient,,,33.48,16.74,,,,,,Other,Not Seperately Reimbuasble,22.77,68,,18.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,20,,5.36,Percent of Total Billed Charges,20% of Total Billed Charges,6.7,20,,5.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,20,,5.36,Percent of Total Billed Charges,20% of Total Billed Charges,6.7,20,,5.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,80,,21.424,Percent of Total Billed Charges,80% of Total Billed Charges,28.46,85,,22.768,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,28.46,
METHYLPREDNISOLONE INJ [80 MG/ML],3000414,CDM,636,RC,J1040,HCPCS,Outpatient,,,102.02,51.01,,,,,,Other,Not Seperately Reimbuasble,69.37,68,,55.496,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.4,20,,16.32,Percent of Total Billed Charges,20% of Total Billed Charges,20.4,20,,16.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.4,20,,16.32,Percent of Total Billed Charges,20% of Total Billed Charges,20.4,20,,16.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.62,80,,65.296,Percent of Total Billed Charges,80% of Total Billed Charges,86.72,85,,69.376,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.4,86.72,
METOCLOPRAMIDE INJ [10 MG/2 ML],3000415,CDM,636,RC,J2765,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
METOCLOPRAMIDE SOL [10 MG/10 ML],3000416,CDM,250,RC,,,Outpatient,,,11.48,5.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.3,20,,1.84,Percent of Total Billed Charges,20% of Total Billed Charges,2.3,20,,1.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.3,20,,1.84,Percent of Total Billed Charges,20% of Total Billed Charges,2.3,20,,1.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.46,65,,5.968,Percent of Total Billed Charges,65% of Total Billed Charges,7.46,65,,5.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.3,53.67,
METOCLOPRAMIDE TAB [10 MG],3000417,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
METOLAZONE TAB [5 MG],3000418,CDM,637,RC,,,Outpatient,,,12.15,6.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,20,,1.944,Percent of Total Billed Charges,20% of Total Billed Charges,2.43,20,,1.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,20,,1.944,Percent of Total Billed Charges,20% of Total Billed Charges,2.43,20,,1.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.9,65,,6.32,Percent of Total Billed Charges,65% of Total Billed Charges,7.9,65,,6.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,53.67,
METOPROLOL INJ [5 MG/5 ML],3000419,CDM,636,RC,J3490,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
METOPROLOL SUCC ER TAB [100 MG],3000420,CDM,637,RC,,,Outpatient,,,9.63,4.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.93,20,,1.544,Percent of Total Billed Charges,20% of Total Billed Charges,1.93,20,,1.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.93,20,,1.544,Percent of Total Billed Charges,20% of Total Billed Charges,1.93,20,,1.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.26,65,,5.008,Percent of Total Billed Charges,65% of Total Billed Charges,6.26,65,,5.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.93,53.67,
METOPROLOL SUCC ER TAB [25 MG],3000421,CDM,637,RC,,,Outpatient,,,6.39,3.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,20,,1.024,Percent of Total Billed Charges,20% of Total Billed Charges,1.28,20,,1.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,20,,1.024,Percent of Total Billed Charges,20% of Total Billed Charges,1.28,20,,1.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,65,,3.32,Percent of Total Billed Charges,65% of Total Billed Charges,4.15,65,,3.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,53.67,
METOPROLOL SUCC ER TAB [50 MG],3000422,CDM,637,RC,,,Outpatient,,,6.39,3.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,20,,1.024,Percent of Total Billed Charges,20% of Total Billed Charges,1.28,20,,1.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,20,,1.024,Percent of Total Billed Charges,20% of Total Billed Charges,1.28,20,,1.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,65,,3.32,Percent of Total Billed Charges,65% of Total Billed Charges,4.15,65,,3.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,53.67,
METOPROLOL TAR TAB [25 MG],3000423,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
METOPROLOL TAR TAB [50 MG],3000424,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
metroNIDAZOLE PREMIX [500 MG/100 ML],3000425,CDM,636,RC,J1836,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
metroNIDAZOLE TAB [500 MG],3000426,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
MICONAZOLE [2 %] CRM W/7 DAY APL,3000427,CDM,637,RC,,,Outpatient,,,23.69,11.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,53.67,
MICONAZOLE NITRATE 2% CRM - TUBE,3000428,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
MICONAZOLE NITRATE [200 MG] VAGINAL SUPP,3000429,CDM,637,RC,,,Outpatient,,,15,7.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,53.67,
MIDAZOLAM INJ [10 MG/2 ML],3000430,CDM,636,RC,J2250,HCPCS,Outpatient,,,31.42,15.71,,,,,,Other,Not Seperately Reimbuasble,21.37,68,,17.096,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.28,20,,5.024,Percent of Total Billed Charges,20% of Total Billed Charges,6.28,20,,5.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.28,20,,5.024,Percent of Total Billed Charges,20% of Total Billed Charges,6.28,20,,5.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.14,80,,20.112,Percent of Total Billed Charges,80% of Total Billed Charges,26.71,85,,21.368,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.28,26.71,
MIDAZOLAM INJ [2 MG/2 ML],3000431,CDM,636,RC,J2250,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
MIDODRINE [5 MG] TAB,3000432,CDM,637,RC,,,Outpatient,,,21.42,10.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.28,20,,3.424,Percent of Total Billed Charges,20% of Total Billed Charges,4.28,20,,3.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.28,20,,3.424,Percent of Total Billed Charges,20% of Total Billed Charges,4.28,20,,3.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.92,65,,11.136,Percent of Total Billed Charges,65% of Total Billed Charges,13.92,65,,11.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.28,53.67,
MINERAL OIL ENEMA,3000433,CDM,637,RC,,,Outpatient,,,18.64,9.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.73,20,,2.984,Percent of Total Billed Charges,20% of Total Billed Charges,3.73,20,,2.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.73,20,,2.984,Percent of Total Billed Charges,20% of Total Billed Charges,3.73,20,,2.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.12,65,,9.696,Percent of Total Billed Charges,65% of Total Billed Charges,12.12,65,,9.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.73,53.67,
MIRTAZAPINE TAB [15 MG],3000434,CDM,637,RC,,,Outpatient,,,14.73,7.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,20,,2.36,Percent of Total Billed Charges,20% of Total Billed Charges,2.95,20,,2.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,20,,2.36,Percent of Total Billed Charges,20% of Total Billed Charges,2.95,20,,2.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.57,65,,7.656,Percent of Total Billed Charges,65% of Total Billed Charges,9.57,65,,7.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,53.67,
MONTELUKAST TAB [10 MG],3000435,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
MORPHINE [10 MG/ML] INJ,3000436,CDM,636,RC,J2270,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
MORPHINE [15 MG] IR TAB,3000437,CDM,637,RC,,,Outpatient,,,8.19,4.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,20,,1.312,Percent of Total Billed Charges,20% of Total Billed Charges,1.64,20,,1.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,20,,1.312,Percent of Total Billed Charges,20% of Total Billed Charges,1.64,20,,1.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.32,65,,4.256,Percent of Total Billed Charges,65% of Total Billed Charges,5.32,65,,4.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,53.67,
MORPHINE [2 MG/ML] INJ,3000438,CDM,636,RC,J2270,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
MORPHINE [4 MG/ML] INJ,3000439,CDM,636,RC,J2270,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
MORPHINE ER TAB [30 MG],3000440,CDM,637,RC,,,Outpatient,,,13.49,6.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,2.7,20,,2.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.77,65,,7.016,Percent of Total Billed Charges,65% of Total Billed Charges,8.77,65,,7.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,53.67,
MORPHINE ORAL SOL [10 MG/0.5 ML],3000441,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
MUPIROCIN OINT [2%] (BACTROBAN),3000442,CDM,637,RC,,,Outpatient,,,51.5,25.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,53.67,
MVI (BETA CAR/VIT A/C/E/MIN)  TAB,3000443,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
"MVI (VIT B COM, BIOTIN, FA) TAB",3000444,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
"MVI (VIT- B COM/ C/ FE,FA/MIN) TAB",3000445,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
MVI COMPLEX CHEWABLE TAB,3000446,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
MVI COMPLEX INJ,3000447,CDM,258,RC,,,Outpatient,,,61.34,30.67,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.27,20,,9.816,Percent of Total Billed Charges,20% of Total Billed Charges,12.27,20,,9.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.27,20,,9.816,Percent of Total Billed Charges,20% of Total Billed Charges,12.27,20,,9.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.87,65,,31.896,Percent of Total Billed Charges,65% of Total Billed Charges,39.87,65,,31.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.27,53.67,
MVI COMPLEX TAB (THERA-M),3000448,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
NAFCILLIN SOD  INJ [1000 MG] *IM*,3000449,CDM,636,RC,,,Outpatient,,,67.67,33.84,,,,,,Other,Not Seperately Reimbuasble,46.02,68,,36.816,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.53,20,,10.824,Percent of Total Billed Charges,20% of Total Billed Charges,13.53,20,,10.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.53,20,,10.824,Percent of Total Billed Charges,20% of Total Billed Charges,13.53,20,,10.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.14,80,,43.312,Percent of Total Billed Charges,80% of Total Billed Charges,57.52,85,,46.016,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.53,57.52,
NALOXONE INJ [0.4 MG/ML],3000450,CDM,636,RC,J2310,HCPCS,Outpatient,,,83.33,41.67,,,,,,Other,Not Seperately Reimbuasble,56.66,68,,45.328,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.67,20,,13.336,Percent of Total Billed Charges,20% of Total Billed Charges,16.67,20,,13.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.67,20,,13.336,Percent of Total Billed Charges,20% of Total Billed Charges,16.67,20,,13.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.66,80,,53.328,Percent of Total Billed Charges,80% of Total Billed Charges,70.83,85,,56.664,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.67,70.83,
NALOXONE INJ SYR [2 MG/2 ML],3000451,CDM,636,RC,J2310,HCPCS,Outpatient,,,91.77,45.89,,,,,,Other,Not Seperately Reimbuasble,62.4,68,,49.92,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.35,20,,14.68,Percent of Total Billed Charges,20% of Total Billed Charges,18.35,20,,14.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.35,20,,14.68,Percent of Total Billed Charges,20% of Total Billed Charges,18.35,20,,14.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.42,80,,58.736,Percent of Total Billed Charges,80% of Total Billed Charges,78,85,,62.4,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.35,78,
NAPROXEN TAB [500 MG],3000452,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
NASAL SALINE SPRAY,3000453,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
NEO/ BAC/ POLY OINT [15 GM],3000454,CDM,250,RC,,,Outpatient,,,11.12,5.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.22,20,,1.776,Percent of Total Billed Charges,20% of Total Billed Charges,2.22,20,,1.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.22,20,,1.776,Percent of Total Billed Charges,20% of Total Billed Charges,2.22,20,,1.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.23,65,,5.784,Percent of Total Billed Charges,65% of Total Billed Charges,7.23,65,,5.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.22,53.67,
NEO/ BAC/ POLY PACKET [0.5 GM],3000455,CDM,250,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
NEO/ POLY/ HYDROCORTISONE OTIC [7.5 ML],3000456,CDM,250,RC,,,Outpatient,,,88.27,44.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.65,20,,14.12,Percent of Total Billed Charges,20% of Total Billed Charges,17.65,20,,14.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.65,20,,14.12,Percent of Total Billed Charges,20% of Total Billed Charges,17.65,20,,14.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.38,65,,45.904,Percent of Total Billed Charges,65% of Total Billed Charges,57.38,65,,45.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.65,57.38,
NEOSTIGMINE [10 MG/10 ML] MDV,3000457,CDM,250,RC,J2710,HCPCS,Outpatient,,,102.12,51.06,,66.38,65,,53.104,Percent of Total Billed Charges,65% of Total Billed Charges,69.44,68,,55.552,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.42,20,,16.336,Percent of Total Billed Charges,20% of Total Billed Charges,20.42,20,,16.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.42,20,,16.336,Percent of Total Billed Charges,20% of Total Billed Charges,20.42,20,,16.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.38,65,,53.104,Percent of Total Billed Charges,65% of Total Billed Charges,66.38,65,,53.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.42,69.44,
NICARDIPINE HCL INJ [25mg/10ml] SDV,3000458,CDM,636,RC,J3490,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
NICOTINE PAT [14 MG/24HR],3000459,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
NICOTINE PAT [21 MG/24HR],3000460,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
NIFEdipine ER TAB [30 MG],3000461,CDM,637,RC,,,Outpatient,,,6.8,3.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,53.67,
NITROFURANTOIN CAP [100 MG],3000462,CDM,637,RC,,,Outpatient,,,17.41,8.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.48,20,,2.784,Percent of Total Billed Charges,20% of Total Billed Charges,3.48,20,,2.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.48,20,,2.784,Percent of Total Billed Charges,20% of Total Billed Charges,3.48,20,,2.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.32,65,,9.056,Percent of Total Billed Charges,65% of Total Billed Charges,11.32,65,,9.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.48,53.67,
NITROGLYCERIN [0.2 MG/HR] PATCH,3000463,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
NITROGLYCERIN [0.4 MG/HR] PATCH,3000464,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
INF- NITROGLYCERIN [50 MG/250 ML] PREMIX,3000465,CDM,250,RC,,,Outpatient,,,107.53,53.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.51,20,,17.208,Percent of Total Billed Charges,20% of Total Billed Charges,21.51,20,,17.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.51,20,,17.208,Percent of Total Billed Charges,20% of Total Billed Charges,21.51,20,,17.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.89,65,,55.912,Percent of Total Billed Charges,65% of Total Billed Charges,69.89,65,,55.912,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.51,69.89,
NITROGLYCERIN 2% OINT [PKT],3000466,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
NITROGLYCERIN SL TAB [0.4 MG],3000467,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
NITROPRUSSIDE SODIUM [50 MG/2 ML],3000468,CDM,250,RC,,,Outpatient,,,444.96,222.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.99,20,,71.192,Percent of Total Billed Charges,20% of Total Billed Charges,88.99,20,,71.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.99,20,,71.192,Percent of Total Billed Charges,20% of Total Billed Charges,88.99,20,,71.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.22,65,,231.376,Percent of Total Billed Charges,65% of Total Billed Charges,289.22,65,,231.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,289.22,
NOREPINEPHRINE BITARTRATE [4 MG/4 ML],3000469,CDM,636,RC,J3490,HCPCS,Outpatient,,,105.52,52.76,,,,,,Other,Not Seperately Reimbuasble,71.75,68,,57.4,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,20,,16.88,Percent of Total Billed Charges,20% of Total Billed Charges,21.1,20,,16.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,20,,16.88,Percent of Total Billed Charges,20% of Total Billed Charges,21.1,20,,16.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.42,80,,67.536,Percent of Total Billed Charges,80% of Total Billed Charges,89.69,85,,71.752,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,89.69,
"NYSTATIN CRM [100,000 UNT/GM] -15GM",3000470,CDM,637,RC,,,Outpatient,,,36.05,18.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,53.67,
"NYSTATIN CRM [100,000 UNT/GM] -30 GM",3000471,CDM,637,RC,,,Outpatient,,,54.08,27.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,20,,8.656,Percent of Total Billed Charges,20% of Total Billed Charges,10.82,20,,8.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,20,,8.656,Percent of Total Billed Charges,20% of Total Billed Charges,10.82,20,,8.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.15,65,,28.12,Percent of Total Billed Charges,65% of Total Billed Charges,35.15,65,,28.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,53.67,
"NYSTATIN ORAL SUSP [500,000 UNITS/5ML]",3000472,CDM,250,RC,,,Outpatient,,,7.93,3.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,65,,4.12,Percent of Total Billed Charges,65% of Total Billed Charges,5.15,65,,4.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,53.67,
NYSTATIN POWDER [100 MU/GM],3000473,CDM,250,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
OCTREOTIDE [0.05 MG/ML] INJ,3000474,CDM,636,RC,J2354,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
OFLOXACIN OPTH/OTIC  [0.3%],3000475,CDM,637,RC,,,Outpatient,,,97.85,48.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,63.6,
OLANZapine TAB [20 MG],3000476,CDM,637,RC,,,Outpatient,,,205.12,102.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.02,20,,32.816,Percent of Total Billed Charges,20% of Total Billed Charges,41.02,20,,32.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.02,20,,32.816,Percent of Total Billed Charges,20% of Total Billed Charges,41.02,20,,32.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.33,65,,106.664,Percent of Total Billed Charges,65% of Total Billed Charges,133.33,65,,106.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.02,133.33,
OLANZapine TAB [5 MG],3000477,CDM,637,RC,,,Outpatient,,,68.08,34.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.25,65,,35.4,Percent of Total Billed Charges,65% of Total Billed Charges,44.25,65,,35.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,53.67,
OMEGA-3-FISH OIL CAP [1000 MG],3000478,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
ONDANSETRON INJ [4 MG/2 ML],3000479,CDM,636,RC,J2405,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
ONDANSETRON OD TAB [4 MG],3000480,CDM,637,RC,J3490,HCPCS,Outpatient,,,5.15,2.58,,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ORPHENADRINE [60 MG/2 ML] INJ -*IM/IV*,3000481,CDM,636,RC,J2360,HCPCS,Outpatient,,,102.95,51.48,,,,,,Other,Not Seperately Reimbuasble,70.01,68,,56.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.59,20,,16.472,Percent of Total Billed Charges,20% of Total Billed Charges,20.59,20,,16.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.59,20,,16.472,Percent of Total Billed Charges,20% of Total Billed Charges,20.59,20,,16.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.36,80,,65.888,Percent of Total Billed Charges,80% of Total Billed Charges,87.51,85,,70.008,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.59,87.51,
OSELTAMIVIR [6 MG/ML] SUSP,3000482,CDM,636,RC,J3490,HCPCS,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,80,,3.296,Percent of Total Billed Charges,80% of Total Billed Charges,4.38,85,,3.504,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,4.38,
OSELTAMIVIR CAP [75 MG],3000483,CDM,637,RC,,,Outpatient,,,93.88,46.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.78,20,,15.024,Percent of Total Billed Charges,20% of Total Billed Charges,18.78,20,,15.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.78,20,,15.024,Percent of Total Billed Charges,20% of Total Billed Charges,18.78,20,,15.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.02,65,,48.816,Percent of Total Billed Charges,65% of Total Billed Charges,61.02,65,,48.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.78,61.02,
OXcarbazepine TAB [150 MG],3000484,CDM,637,RC,,,Outpatient,,,7.42,3.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,1.48,20,,1.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,65,,3.856,Percent of Total Billed Charges,65% of Total Billed Charges,4.82,65,,3.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,53.67,
OXYBUTYNIN ER TAB [5MG],3000485,CDM,637,RC,,,Outpatient,,,14.16,7.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.83,20,,2.264,Percent of Total Billed Charges,20% of Total Billed Charges,2.83,20,,2.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.83,20,,2.264,Percent of Total Billed Charges,20% of Total Billed Charges,2.83,20,,2.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,65,,7.36,Percent of Total Billed Charges,65% of Total Billed Charges,9.2,65,,7.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.83,53.67,
OXYBUTYNIN TAB [5 MG],3000486,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
oxyCODONE ER TAB [10 MG],3000487,CDM,250,RC,,,Outpatient,,,40.69,20.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,20,,6.512,Percent of Total Billed Charges,20% of Total Billed Charges,8.14,20,,6.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,20,,6.512,Percent of Total Billed Charges,20% of Total Billed Charges,8.14,20,,6.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.45,65,,21.16,Percent of Total Billed Charges,65% of Total Billed Charges,26.45,65,,21.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,53.67,
oxyCODONE IR TAB [5 MG],3000488,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
oxyCODONE/ ACET TAB [10-325 MG],3000489,CDM,637,RC,,,Outpatient,,,30.23,15.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.05,20,,4.84,Percent of Total Billed Charges,20% of Total Billed Charges,6.05,20,,4.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.05,20,,4.84,Percent of Total Billed Charges,20% of Total Billed Charges,6.05,20,,4.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.65,65,,15.72,Percent of Total Billed Charges,65% of Total Billed Charges,19.65,65,,15.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.05,53.67,
oxyCODONE/ ACET TAB [5-325 MG],3000490,CDM,637,RC,,,Outpatient,,,12.31,6.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,20,,1.968,Percent of Total Billed Charges,20% of Total Billed Charges,2.46,20,,1.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,20,,1.968,Percent of Total Billed Charges,20% of Total Billed Charges,2.46,20,,1.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,65,,6.4,Percent of Total Billed Charges,65% of Total Billed Charges,8,65,,6.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,53.67,
OXYMETAZOLINE NASAL SPRAY,3000491,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
OXYTOCIN [10 UNITS/ML],3000492,CDM,636,RC,J2590,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
"PANCRELIPASE 10,440-39,150-39,150U TAB",3000493,CDM,637,RC,,,Outpatient,,,19.93,9.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.99,20,,3.192,Percent of Total Billed Charges,20% of Total Billed Charges,3.99,20,,3.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.99,20,,3.192,Percent of Total Billed Charges,20% of Total Billed Charges,3.99,20,,3.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.95,65,,10.36,Percent of Total Billed Charges,65% of Total Billed Charges,12.95,65,,10.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.99,53.67,
PANTOPRAZOLE SOD INJ [40 MG] **IVP-S**,3000494,CDM,250,RC,,,Outpatient,,,27.81,13.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,53.67,
PANTOPRAZOLE SOD DR TAB [20 MG],3000495,CDM,637,RC,,,Outpatient,,,20.55,10.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.11,20,,3.288,Percent of Total Billed Charges,20% of Total Billed Charges,4.11,20,,3.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.11,20,,3.288,Percent of Total Billed Charges,20% of Total Billed Charges,4.11,20,,3.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.36,65,,10.688,Percent of Total Billed Charges,65% of Total Billed Charges,13.36,65,,10.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.11,53.67,
PANTOPRAZOLE SOD TAB [40 MG],3000496,CDM,637,RC,,,Outpatient,,,21.06,10.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.21,20,,3.368,Percent of Total Billed Charges,20% of Total Billed Charges,4.21,20,,3.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.21,20,,3.368,Percent of Total Billed Charges,20% of Total Billed Charges,4.21,20,,3.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.69,65,,10.952,Percent of Total Billed Charges,65% of Total Billed Charges,13.69,65,,10.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.21,53.67,
PARoxetine TAB [20 MG],3000497,CDM,637,RC,,,Outpatient,,,14.06,7.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.81,20,,2.248,Percent of Total Billed Charges,20% of Total Billed Charges,2.81,20,,2.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.81,20,,2.248,Percent of Total Billed Charges,20% of Total Billed Charges,2.81,20,,2.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.14,65,,7.312,Percent of Total Billed Charges,65% of Total Billed Charges,9.14,65,,7.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.81,53.67,
PENICILLIN VK SUSP [125 MG/5 ML],3000498,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
PENICILLIN VK TAB [250 MG],3000499,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
PERMETHRIN 1 % CRM-LICE TREATMENT KIT,3000500,CDM,250,RC,,,Outpatient,,,44.39,22.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.88,20,,7.104,Percent of Total Billed Charges,20% of Total Billed Charges,8.88,20,,7.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.88,20,,7.104,Percent of Total Billed Charges,20% of Total Billed Charges,8.88,20,,7.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.85,65,,23.08,Percent of Total Billed Charges,65% of Total Billed Charges,28.85,65,,23.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.88,53.67,
PERMETHRIN 5% SCABIES CRM,3000501,CDM,637,RC,,,Outpatient,,,244.73,122.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.95,20,,39.16,Percent of Total Billed Charges,20% of Total Billed Charges,48.95,20,,39.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.95,20,,39.16,Percent of Total Billed Charges,20% of Total Billed Charges,48.95,20,,39.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.07,65,,127.256,Percent of Total Billed Charges,65% of Total Billed Charges,159.07,65,,127.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.95,159.07,
PHARMACY CONSULT,3000502,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PHENAZOPYRIDINE TAB [200 MG],3000503,CDM,637,RC,,,Outpatient,,,20.6,10.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,53.67,
PHENOBARBITAL TAB [32.4 MG],3000504,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
PHENYLEPHRINE [500 MCG/5ML] INJ - PF,3000505,CDM,636,RC,J2372,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
PHENYLEPHRINE HCL INJ [10 MG/ML],3000506,CDM,636,RC,J2371,HCPCS,Outpatient,,,33.37,16.69,,,,,,Other,Not Seperately Reimbuasble,22.69,68,,18.152,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,6.67,20,,5.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.7,80,,21.36,Percent of Total Billed Charges,80% of Total Billed Charges,28.36,85,,22.688,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,28.36,
PHENYTOIN ER CAP [100 MG],3000507,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
PHENYTOIN ORAL SUSP [125 MG/5ML],3000508,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
PHENYTOIN SOD INJ [250 MG/5 ML],3000509,CDM,636,RC,J1165,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
PIOGLITAZONE TAB [15 MG],3000510,CDM,637,RC,,,Outpatient,,,36.1,18.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.22,20,,5.776,Percent of Total Billed Charges,20% of Total Billed Charges,7.22,20,,5.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.22,20,,5.776,Percent of Total Billed Charges,20% of Total Billed Charges,7.22,20,,5.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.47,65,,18.776,Percent of Total Billed Charges,65% of Total Billed Charges,23.47,65,,18.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.22,53.67,
PIPERACILLIN/ TAZO [2.25 GM] VIAL,3000511,CDM,636,RC,J2543,HCPCS,Outpatient,,,38.21,19.11,,,,,,Other,Not Seperately Reimbuasble,25.98,68,,20.784,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.64,20,,6.112,Percent of Total Billed Charges,20% of Total Billed Charges,7.64,20,,6.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.64,20,,6.112,Percent of Total Billed Charges,20% of Total Billed Charges,7.64,20,,6.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.57,80,,24.456,Percent of Total Billed Charges,80% of Total Billed Charges,32.48,85,,25.984,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.64,32.48,
PIPERACILLIN/ TAZO [3.375 GM] VIAL,3000512,CDM,636,RC,J2543,HCPCS,Outpatient,,,100.84,50.42,,,,,,Other,Not Seperately Reimbuasble,68.57,68,,54.856,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.17,20,,16.136,Percent of Total Billed Charges,20% of Total Billed Charges,20.17,20,,16.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.17,20,,16.136,Percent of Total Billed Charges,20% of Total Billed Charges,20.17,20,,16.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.67,80,,64.536,Percent of Total Billed Charges,80% of Total Billed Charges,85.71,85,,68.568,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.17,85.71,
PIPERACILLIN/ TAZO [4.5 GM] VIAL,3000513,CDM,636,RC,J2543,HCPCS,Outpatient,,,85.49,42.75,,,,,,Other,Not Seperately Reimbuasble,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.39,80,,54.712,Percent of Total Billed Charges,80% of Total Billed Charges,72.67,85,,58.136,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,72.67,
POLYETH GLYCL 3350 [17 GM] PKT,3000514,CDM,250,RC,,,Outpatient,,,9.73,4.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,1.95,20,,1.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.32,65,,5.056,Percent of Total Billed Charges,65% of Total Billed Charges,6.32,65,,5.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,53.67,
POTASSIUM CL LIQ [20 MEQ/15 ML],3000515,CDM,637,RC,,,Outpatient,,,78.38,39.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.68,20,,12.544,Percent of Total Billed Charges,20% of Total Billed Charges,15.68,20,,12.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.68,20,,12.544,Percent of Total Billed Charges,20% of Total Billed Charges,15.68,20,,12.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.95,65,,40.76,Percent of Total Billed Charges,65% of Total Billed Charges,50.95,65,,40.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.68,53.67,
POTASSIUM CL TAB [10 MEQ],3000516,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
POTASSIUM CL TAB [20 MEQ],3000517,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
PPD READING,3000518,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PRAMIPEXOLE TAB [0.25 MG],3000519,CDM,637,RC,,,Outpatient,,,15.14,7.57,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,20,,2.424,Percent of Total Billed Charges,20% of Total Billed Charges,3.03,20,,2.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,20,,2.424,Percent of Total Billed Charges,20% of Total Billed Charges,3.03,20,,2.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.84,65,,7.872,Percent of Total Billed Charges,65% of Total Billed Charges,9.84,65,,7.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,53.67,
PRAVASTATIN TAB [20 MG],3000520,CDM,637,RC,,,Outpatient,,,12.88,6.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.37,65,,6.696,Percent of Total Billed Charges,65% of Total Billed Charges,8.37,65,,6.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,53.67,
PRAVASTATIN TAB [40 MG],3000521,CDM,637,RC,,,Outpatient,,,22.15,11.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.43,20,,3.544,Percent of Total Billed Charges,20% of Total Billed Charges,4.43,20,,3.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.43,20,,3.544,Percent of Total Billed Charges,20% of Total Billed Charges,4.43,20,,3.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,65,,11.52,Percent of Total Billed Charges,65% of Total Billed Charges,14.4,65,,11.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.43,53.67,
prednisoLONE LIQ [15 MG/5 ML],3000522,CDM,637,RC,,,Outpatient,,,8.14,4.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.29,65,,4.232,Percent of Total Billed Charges,65% of Total Billed Charges,5.29,65,,4.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,53.67,
prednisoLONE OPTH/OTIC [1 %],3000523,CDM,637,RC,,,Outpatient,,,113.97,56.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.79,20,,18.232,Percent of Total Billed Charges,20% of Total Billed Charges,22.79,20,,18.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.79,20,,18.232,Percent of Total Billed Charges,20% of Total Billed Charges,22.79,20,,18.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.08,65,,59.264,Percent of Total Billed Charges,65% of Total Billed Charges,74.08,65,,59.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.79,74.08,
predniSONE TAB [20 MG],3000524,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
predniSONE TAB [5 MG],3000525,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
PREGABALIN CAP [100 MG],3000526,CDM,637,RC,,,Outpatient,,,9.06,4.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.81,20,,1.448,Percent of Total Billed Charges,20% of Total Billed Charges,1.81,20,,1.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.81,20,,1.448,Percent of Total Billed Charges,20% of Total Billed Charges,1.81,20,,1.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.89,65,,4.712,Percent of Total Billed Charges,65% of Total Billed Charges,5.89,65,,4.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.81,53.67,
PREGABALIN CAP [25 MG],3000527,CDM,637,RC,,,Outpatient,,,14.21,7.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.84,20,,2.272,Percent of Total Billed Charges,20% of Total Billed Charges,2.84,20,,2.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.84,20,,2.272,Percent of Total Billed Charges,20% of Total Billed Charges,2.84,20,,2.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.24,65,,7.392,Percent of Total Billed Charges,65% of Total Billed Charges,9.24,65,,7.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.84,53.67,
PREGABALIN CAP [50 MG],3000528,CDM,637,RC,,,Outpatient,,,8.14,4.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,1.63,20,,1.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.29,65,,4.232,Percent of Total Billed Charges,65% of Total Billed Charges,5.29,65,,4.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,53.67,
PREGABALIN CAP [75 MG],3000529,CDM,637,RC,,,Outpatient,,,8.29,4.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,20,,1.328,Percent of Total Billed Charges,20% of Total Billed Charges,1.66,20,,1.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,20,,1.328,Percent of Total Billed Charges,20% of Total Billed Charges,1.66,20,,1.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,65,,4.312,Percent of Total Billed Charges,65% of Total Billed Charges,5.39,65,,4.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,53.67,
PRIMIDONE TAB [50 MG],3000530,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
PROCHLORPERAZINE INJ [10 MG/2 ML],3000531,CDM,636,RC,J0780,HCPCS,Outpatient,,,102.9,51.45,,,,,,Other,Not Seperately Reimbuasble,69.97,68,,55.976,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,20,,16.464,Percent of Total Billed Charges,20% of Total Billed Charges,20.58,20,,16.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,20,,16.464,Percent of Total Billed Charges,20% of Total Billed Charges,20.58,20,,16.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.32,80,,65.856,Percent of Total Billed Charges,80% of Total Billed Charges,87.47,85,,69.976,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,87.47,
PROMETHAZINE [25 MG/ML] IM,3000532,CDM,636,RC,J2550,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
PROMETHAZINE SUPP [12.5 MG],3000533,CDM,637,RC,,,Outpatient,,,120.56,60.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,20,,19.288,Percent of Total Billed Charges,20% of Total Billed Charges,24.11,20,,19.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,20,,19.288,Percent of Total Billed Charges,20% of Total Billed Charges,24.11,20,,19.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.36,65,,62.688,Percent of Total Billed Charges,65% of Total Billed Charges,78.36,65,,62.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,78.36,
PROMETHAZINE SUPP [25 MG],3000534,CDM,637,RC,,,Outpatient,,,120.56,60.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,20,,19.288,Percent of Total Billed Charges,20% of Total Billed Charges,24.11,20,,19.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,20,,19.288,Percent of Total Billed Charges,20% of Total Billed Charges,24.11,20,,19.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.36,65,,62.688,Percent of Total Billed Charges,65% of Total Billed Charges,78.36,65,,62.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,78.36,
PROMETHAZINE TAB [25 MG],3000535,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
INF-PROPOFOL [200 MG/20 ML] PREMIXED,3000536,CDM,636,RC,J2704,HCPCS,Outpatient,,,32.5,16.25,,,,,,Other,Not Seperately Reimbuasble,22.1,68,,17.68,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,20,,5.2,Percent of Total Billed Charges,20% of Total Billed Charges,6.5,20,,5.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,20,,5.2,Percent of Total Billed Charges,20% of Total Billed Charges,6.5,20,,5.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,80,,20.8,Percent of Total Billed Charges,80% of Total Billed Charges,27.63,85,,22.104,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,27.63,
INF- PROPOFOL [500 MG/50 ML] PREMIXED,3000537,CDM,636,RC,J2704,HCPCS,Outpatient,,,83.43,41.72,,,,,,Other,Not Seperately Reimbuasble,56.73,68,,45.384,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.74,80,,53.392,Percent of Total Billed Charges,80% of Total Billed Charges,70.92,85,,56.736,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,70.92,
PROPRANOLOL [20 MG] TAB,3000538,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
PRO-STAT 64 [1 fl oz (30 mL) PKT],3000539,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
QUETiapine [100 MG] TAB,3000540,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
QUEtiapine TAB [25 MG],3000541,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
QUETiapine TAB [300 MG],3000542,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
RALOXIFENE TAB [60 MG],3000543,CDM,637,RC,,,Outpatient,,,36.67,18.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.33,20,,5.864,Percent of Total Billed Charges,20% of Total Billed Charges,7.33,20,,5.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.33,20,,5.864,Percent of Total Billed Charges,20% of Total Billed Charges,7.33,20,,5.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.84,65,,19.072,Percent of Total Billed Charges,65% of Total Billed Charges,23.84,65,,19.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.33,53.67,
RANOLAZINE ER TAB [500 MG],3000544,CDM,637,RC,,,Outpatient,,,33.11,16.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.62,20,,5.296,Percent of Total Billed Charges,20% of Total Billed Charges,6.62,20,,5.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.62,20,,5.296,Percent of Total Billed Charges,20% of Total Billed Charges,6.62,20,,5.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.52,65,,17.216,Percent of Total Billed Charges,65% of Total Billed Charges,21.52,65,,17.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.62,53.67,
REMDESIVIR [100 MG] SDV,3000545,CDM,636,RC,J3490,HCPCS,Outpatient,,,931.94,465.97,,605.76,65,,484.608,Percent of Total Billed Charges,65% of Total Billed Charges,633.72,68,,506.976,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.39,20,,149.112,Percent of Total Billed Charges,20% of Total Billed Charges,186.39,20,,149.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.39,20,,149.112,Percent of Total Billed Charges,20% of Total Billed Charges,186.39,20,,149.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745.55,80,,596.44,Percent of Total Billed Charges,80% of Total Billed Charges,792.15,85,,633.72,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.39,792.15,
RESPIRATORY MEDICATION,3000546,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
risperIDONE TAB [0.5 MG],3000547,CDM,637,RC,,,Outpatient,,,20.29,10.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,20,,3.248,Percent of Total Billed Charges,20% of Total Billed Charges,4.06,20,,3.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,20,,3.248,Percent of Total Billed Charges,20% of Total Billed Charges,4.06,20,,3.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,65,,10.552,Percent of Total Billed Charges,65% of Total Billed Charges,13.19,65,,10.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,53.67,
risperiDONE TAB [1 MG],3000548,CDM,637,RC,,,Outpatient,,,23.54,11.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.71,20,,3.768,Percent of Total Billed Charges,20% of Total Billed Charges,4.71,20,,3.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.71,20,,3.768,Percent of Total Billed Charges,20% of Total Billed Charges,4.71,20,,3.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,65,,12.24,Percent of Total Billed Charges,65% of Total Billed Charges,15.3,65,,12.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.71,53.67,
RIVAROXABAN TAB [10 MG],3000549,CDM,637,RC,,,Outpatient,,,96.82,48.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,62.93,
RIVAROXABAN TAB [15 MG],3000550,CDM,637,RC,,,Outpatient,,,96.82,48.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,62.93,
RIVAROXABAN TAB [20 MG],3000551,CDM,637,RC,,,Outpatient,,,96.82,48.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,62.93,
ROCURONIUM BR [50 MG/5ML] MDV,3000552,CDM,250,RC,,,Outpatient,,,26.11,13.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,20,,4.176,Percent of Total Billed Charges,20% of Total Billed Charges,5.22,20,,4.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,20,,4.176,Percent of Total Billed Charges,20% of Total Billed Charges,5.22,20,,4.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.97,65,,13.576,Percent of Total Billed Charges,65% of Total Billed Charges,16.97,65,,13.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,53.67,
rOPINIRole TAB [0.5 MG],3000553,CDM,637,RC,,,Outpatient,,,12.88,6.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.37,65,,6.696,Percent of Total Billed Charges,65% of Total Billed Charges,8.37,65,,6.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,53.67,
rOPINIRole TAB [1 MG],3000554,CDM,637,RC,,,Outpatient,,,12.88,6.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.37,65,,6.696,Percent of Total Billed Charges,65% of Total Billed Charges,8.37,65,,6.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,53.67,
RT- ACETYLCYSTEINE SOL 20% [4  ML],3000555,CDM,250,RC,J7608,HCPCS,Outpatient,,,77.1,38.55,,50.12,65,,40.096,Percent of Total Billed Charges,65% of Total Billed Charges,52.43,68,,41.944,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.42,20,,12.336,Percent of Total Billed Charges,20% of Total Billed Charges,15.42,20,,12.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.42,20,,12.336,Percent of Total Billed Charges,20% of Total Billed Charges,15.42,20,,12.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.12,65,,40.096,Percent of Total Billed Charges,65% of Total Billed Charges,50.12,65,,40.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.42,53.67,
RT- ALBUTEROL MDI [90 MCG/ACT],3000556,CDM,636,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,3.5,68,,2.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,80,,3.296,Percent of Total Billed Charges,80% of Total Billed Charges,4.38,85,,3.504,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,4.38,
RT- ALBUTEROL NEB [1.25  MG/3 ML],3000557,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
RT- ALBUTEROL NEB [2.5 MG/3 ML],3000558,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
RT- ALBUTEROL/IPRATROPIUM NEB,3000559,CDM,250,RC,,,Outpatient,,,11.28,5.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,2.26,20,,1.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.33,65,,5.864,Percent of Total Billed Charges,65% of Total Billed Charges,7.33,65,,5.864,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,53.67,
RT- BUDESONIDE NEB [0.5 MG/2 ML],3000560,CDM,250,RC,,,Outpatient,,,63.4,31.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.68,20,,10.144,Percent of Total Billed Charges,20% of Total Billed Charges,12.68,20,,10.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.68,20,,10.144,Percent of Total Billed Charges,20% of Total Billed Charges,12.68,20,,10.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.21,65,,32.968,Percent of Total Billed Charges,65% of Total Billed Charges,41.21,65,,32.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.68,53.67,
RT- IPRATROPIUM NEB [0.02 %],3000561,CDM,250,RC,,,Outpatient,,,6.8,3.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,1.36,20,,1.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,4.42,65,,3.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,53.67,
RT- LEVALBUTEROL NEB [1.25 MG/3 ML],3000562,CDM,250,RC,,,Outpatient,,,34.51,17.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,20,,5.52,Percent of Total Billed Charges,20% of Total Billed Charges,6.9,20,,5.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,20,,5.52,Percent of Total Billed Charges,20% of Total Billed Charges,6.9,20,,5.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.43,65,,17.944,Percent of Total Billed Charges,65% of Total Billed Charges,22.43,65,,17.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,53.67,
RT- MOMETASONE [200 MCG/ACT] MDI,3000563,CDM,250,RC,,,Outpatient,,,22.25,11.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.45,20,,3.56,Percent of Total Billed Charges,20% of Total Billed Charges,4.45,20,,3.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.45,20,,3.56,Percent of Total Billed Charges,20% of Total Billed Charges,4.45,20,,3.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,65,,11.568,Percent of Total Billed Charges,65% of Total Billed Charges,14.46,65,,11.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.45,53.67,
RT- RACEPINEPHRINE NEB 2.25%,3000564,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
RT- SODIUM CHLORIDE [0.9 %] NEB,3000565,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
RT- SODIUM CHLORIDE [3 %] NEB,3000566,CDM,250,RC,,,Outpatient,,,24.72,12.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,65,,12.856,Percent of Total Billed Charges,65% of Total Billed Charges,16.07,65,,12.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.94,53.67,
SCOPOLAMINE PATCH [1.5 MG],3000567,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
SENNA/ DOC SOD [8.6-50 MG] TAB,3000568,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
SENNOSIDES TAB [8.6 MG],3000569,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
SERTRALINE TAB [50 MG],3000570,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
SILVER NITRATE STK,3000571,CDM,250,RC,,,Outpatient,,,34.3,17.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,20,,5.488,Percent of Total Billed Charges,20% of Total Billed Charges,6.86,20,,5.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,20,,5.488,Percent of Total Billed Charges,20% of Total Billed Charges,6.86,20,,5.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.3,65,,17.84,Percent of Total Billed Charges,65% of Total Billed Charges,22.3,65,,17.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,53.67,
SILVER SULFADIAZINE 1% CRM [25 GM],3000572,CDM,250,RC,,,Outpatient,,,18.69,9.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,20,,2.992,Percent of Total Billed Charges,20% of Total Billed Charges,3.74,20,,2.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,20,,2.992,Percent of Total Billed Charges,20% of Total Billed Charges,3.74,20,,2.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.15,65,,9.72,Percent of Total Billed Charges,65% of Total Billed Charges,12.15,65,,9.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,53.67,
SILVER SULFADIAZINE 1% CRM [400 GM],3000573,CDM,250,RC,,,Outpatient,,,133.8,66.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.76,20,,21.408,Percent of Total Billed Charges,20% of Total Billed Charges,26.76,20,,21.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.76,20,,21.408,Percent of Total Billed Charges,20% of Total Billed Charges,26.76,20,,21.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.97,65,,69.576,Percent of Total Billed Charges,65% of Total Billed Charges,86.97,65,,69.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.76,86.97,
SIMETHICONE DRP [20 MG/0.3 ML],3000574,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
SIMETHICONE CHEWABLE TAB [125 MG],3000575,CDM,250,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
sitaGLIPtin TAB [100 MG],3000576,CDM,637,RC,,,Outpatient,,,97.54,48.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.4,65,,50.72,Percent of Total Billed Charges,65% of Total Billed Charges,63.4,65,,50.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,63.4,
sitaGLIPtin TAB [25 MG],3000577,CDM,637,RC,,,Outpatient,,,97.54,48.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.4,65,,50.72,Percent of Total Billed Charges,65% of Total Billed Charges,63.4,65,,50.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,63.4,
sitaGLIPtin TAB [50 MG],3000578,CDM,637,RC,,,Outpatient,,,97.54,48.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,19.51,20,,15.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.4,65,,50.72,Percent of Total Billed Charges,65% of Total Billed Charges,63.4,65,,50.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,63.4,
SOD PHOS MB/ SOD PHOS ENEMA,3000579,CDM,637,RC,,,Outpatient,,,10.4,5.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,20,,1.664,Percent of Total Billed Charges,20% of Total Billed Charges,2.08,20,,1.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,20,,1.664,Percent of Total Billed Charges,20% of Total Billed Charges,2.08,20,,1.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.76,65,,5.408,Percent of Total Billed Charges,65% of Total Billed Charges,6.76,65,,5.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,53.67,
SOD POLY SULF SUSP [15 GM/60 ML],3000580,CDM,250,RC,,,Outpatient,,,112.94,56.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.59,20,,18.072,Percent of Total Billed Charges,20% of Total Billed Charges,22.59,20,,18.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.59,20,,18.072,Percent of Total Billed Charges,20% of Total Billed Charges,22.59,20,,18.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.41,65,,58.728,Percent of Total Billed Charges,65% of Total Billed Charges,73.41,65,,58.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.59,73.41,
SODIUM BICARB INJ SYR [50 MEQ/50ML] 8.4%,3000581,CDM,636,RC,J3490,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
SODIUM BICARB TAB [650 MG],3000582,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
SODIUM CHLORIDE [2 mL] SDV,3000583,CDM,250,RC,,,Outpatient,,,9.68,4.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,20,,1.552,Percent of Total Billed Charges,20% of Total Billed Charges,1.94,20,,1.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,20,,1.552,Percent of Total Billed Charges,20% of Total Billed Charges,1.94,20,,1.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.29,65,,5.032,Percent of Total Billed Charges,65% of Total Billed Charges,6.29,65,,5.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,53.67,
SODIUM CHLORIDE [20 mL] SDV,3000584,CDM,250,RC,,,Outpatient,,,13.54,6.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.71,20,,2.168,Percent of Total Billed Charges,20% of Total Billed Charges,2.71,20,,2.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.71,20,,2.168,Percent of Total Billed Charges,20% of Total Billed Charges,2.71,20,,2.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.8,65,,7.04,Percent of Total Billed Charges,65% of Total Billed Charges,8.8,65,,7.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.71,53.67,
SODIUM CHLORIDE TAB [1000 MG],3000585,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
SODIUM HYPOCHLORITE [0.125 %],3000586,CDM,250,RC,,,Outpatient,,,26.27,13.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.25,20,,4.2,Percent of Total Billed Charges,20% of Total Billed Charges,5.25,20,,4.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.25,20,,4.2,Percent of Total Billed Charges,20% of Total Billed Charges,5.25,20,,4.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.08,65,,13.664,Percent of Total Billed Charges,65% of Total Billed Charges,17.08,65,,13.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.25,53.67,
SODIUM HYPOCHLORITE [0.25 %],3000587,CDM,250,RC,,,Outpatient,,,28.58,14.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.72,20,,4.576,Percent of Total Billed Charges,20% of Total Billed Charges,5.72,20,,4.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.72,20,,4.576,Percent of Total Billed Charges,20% of Total Billed Charges,5.72,20,,4.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.58,65,,14.864,Percent of Total Billed Charges,65% of Total Billed Charges,18.58,65,,14.864,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.72,53.67,
SOTALOL TAB [80 MG],3000588,CDM,637,RC,,,Outpatient,,,13.24,6.62,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,20,,2.12,Percent of Total Billed Charges,20% of Total Billed Charges,2.65,20,,2.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,20,,2.12,Percent of Total Billed Charges,20% of Total Billed Charges,2.65,20,,2.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.61,65,,6.888,Percent of Total Billed Charges,65% of Total Billed Charges,8.61,65,,6.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,53.67,
SPIRONOLACTONE TAB [25 MG],3000589,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
SUCCINYLCHOLINE INJ [200 MG/10 ML],3000590,CDM,636,RC,J0330,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
SUCRALFATE ORAL SUSP [1 GM/10 ML],3000591,CDM,250,RC,,,Outpatient,,,62.73,31.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.55,20,,10.04,Percent of Total Billed Charges,20% of Total Billed Charges,12.55,20,,10.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.55,20,,10.04,Percent of Total Billed Charges,20% of Total Billed Charges,12.55,20,,10.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.77,65,,32.616,Percent of Total Billed Charges,65% of Total Billed Charges,40.77,65,,32.616,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.55,53.67,
SUCRALFATE TAB [1 GM],3000592,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
SULFACETAMIDE OPTH [10 %],3000593,CDM,250,RC,,,Outpatient,,,314.15,157.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,20,,50.264,Percent of Total Billed Charges,20% of Total Billed Charges,62.83,20,,50.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,20,,50.264,Percent of Total Billed Charges,20% of Total Billed Charges,62.83,20,,50.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.2,65,,163.36,Percent of Total Billed Charges,65% of Total Billed Charges,204.2,65,,163.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,204.2,
SULFAMETH/ TMP DS TAB [800-160 MG],3000594,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
SULFAMETH/ TMP SUS [200-40 MG/5ML],3000595,CDM,637,RC,,,Outpatient,,,11.74,5.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.35,20,,1.88,Percent of Total Billed Charges,20% of Total Billed Charges,2.35,20,,1.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.35,20,,1.88,Percent of Total Billed Charges,20% of Total Billed Charges,2.35,20,,1.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.63,65,,6.104,Percent of Total Billed Charges,65% of Total Billed Charges,7.63,65,,6.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.35,53.67,
SULFAMETH/TMP INJ [800-160MG/10ML] *IV*,3000596,CDM,250,RC,J3490,HCPCS,Outpatient,,,69.78,34.89,,45.36,65,,36.288,Percent of Total Billed Charges,65% of Total Billed Charges,47.45,68,,37.96,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.96,20,,11.168,Percent of Total Billed Charges,20% of Total Billed Charges,13.96,20,,11.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.96,20,,11.168,Percent of Total Billed Charges,20% of Total Billed Charges,13.96,20,,11.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.36,65,,36.288,Percent of Total Billed Charges,65% of Total Billed Charges,45.36,65,,36.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.96,53.67,
SUMAtriptan INJ [6 MG/0.5 ML] *SUBQ*,3000597,CDM,636,RC,J3030,HCPCS,Outpatient,,,393.98,196.99,,,,,,Other,Not Seperately Reimbuasble,267.91,68,,214.328,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.8,20,,63.04,Percent of Total Billed Charges,20% of Total Billed Charges,78.8,20,,63.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.8,20,,63.04,Percent of Total Billed Charges,20% of Total Billed Charges,78.8,20,,63.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.18,80,,252.144,Percent of Total Billed Charges,80% of Total Billed Charges,334.88,85,,267.904,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.8,334.88,
SWI USP [10 ML],3000598,CDM,250,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
SWI USP [50 ML],3000599,CDM,250,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
TAMSULOSIN CAP [0.4 MG],3000600,CDM,637,RC,,,Outpatient,,,21.68,10.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,20,,3.472,Percent of Total Billed Charges,20% of Total Billed Charges,4.34,20,,3.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,20,,3.472,Percent of Total Billed Charges,20% of Total Billed Charges,4.34,20,,3.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.09,65,,11.272,Percent of Total Billed Charges,65% of Total Billed Charges,14.09,65,,11.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,53.67,
TEMAZEPAM CAP [15 MG],3000601,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
TEMAZEPAM CAP [30 MG],3000602,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
TENECTEPLASE [50 MG] INJ,3000603,CDM,636,RC,J3101,HCPCS,Outpatient,,,11145.48,5572.74,,7244.56,65,,5795.648,Percent of Total Billed Charges,65% of Total Billed Charges,7578.93,68,,6063.144,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2229.1,20,,1783.28,Percent of Total Billed Charges,20% of Total Billed Charges,2229.1,20,,1783.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2229.1,20,,1783.28,Percent of Total Billed Charges,20% of Total Billed Charges,2229.1,20,,1783.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8916.38,80,,7133.104,Percent of Total Billed Charges,80% of Total Billed Charges,9473.66,85,,7578.928,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2229.1,9473.66,
TERBINAFINE [250 MG] TAB,3000604,CDM,637,RC,,,Outpatient,,,67.1,33.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.42,20,,10.736,Percent of Total Billed Charges,20% of Total Billed Charges,13.42,20,,10.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.42,20,,10.736,Percent of Total Billed Charges,20% of Total Billed Charges,13.42,20,,10.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.62,65,,34.896,Percent of Total Billed Charges,65% of Total Billed Charges,43.62,65,,34.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.42,53.67,
TETRACAINE HCL OPTH [0.5%],3000605,CDM,637,RC,,,Outpatient,,,74.16,37.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,53.67,
TIMOLOL MALEATE OPTH [0.5 %],3000606,CDM,637,RC,,,Outpatient,,,35.02,17.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.76,65,,18.208,Percent of Total Billed Charges,65% of Total Billed Charges,22.76,65,,18.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,53.67,
tiZANidine TAB [4 MG],3000607,CDM,637,RC,,,Outpatient,,,9.12,4.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,20,,1.456,Percent of Total Billed Charges,20% of Total Billed Charges,1.82,20,,1.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,20,,1.456,Percent of Total Billed Charges,20% of Total Billed Charges,1.82,20,,1.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.93,65,,4.744,Percent of Total Billed Charges,65% of Total Billed Charges,5.93,65,,4.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,53.67,
TOBRAMYCIN OPTH [0.3 %],3000608,CDM,637,RC,,,Outpatient,,,74.98,37.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.74,65,,38.992,Percent of Total Billed Charges,65% of Total Billed Charges,48.74,65,,38.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,53.67,
TOBRAMYCIN/DEXAMETHASONE OPTH0.3 %/0.1 %,3000609,CDM,250,RC,,,Outpatient,,,125.04,62.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.01,20,,20.008,Percent of Total Billed Charges,20% of Total Billed Charges,25.01,20,,20.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.01,20,,20.008,Percent of Total Billed Charges,20% of Total Billed Charges,25.01,20,,20.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.28,65,,65.024,Percent of Total Billed Charges,65% of Total Billed Charges,81.28,65,,65.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.01,81.28,
TOCILIZUMAB [20 MG/ML],3000610,CDM,636,RC,,,Outpatient,,,2066.23,1033.12,,1343.05,65,,1074.44,Percent of Total Billed Charges,65% of Total Billed Charges,1405.04,68,,1124.032,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.25,20,,330.6,Percent of Total Billed Charges,20% of Total Billed Charges,413.25,20,,330.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.25,20,,330.6,Percent of Total Billed Charges,20% of Total Billed Charges,413.25,20,,330.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1652.98,80,,1322.384,Percent of Total Billed Charges,80% of Total Billed Charges,1756.3,85,,1405.04,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.25,1756.3,
TOPIRAMATE TAB  [100 MG],3000611,CDM,637,RC,,,Outpatient,,,31.93,15.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.75,65,,16.6,Percent of Total Billed Charges,65% of Total Billed Charges,20.75,65,,16.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,53.67,
TOPIRAMATE TAB  [25 MG],3000612,CDM,637,RC,,,Outpatient,,,10.82,5.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,2.16,20,,1.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.03,65,,5.624,Percent of Total Billed Charges,65% of Total Billed Charges,7.03,65,,5.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,53.67,
TORSEMIDE TAB [100 MG],3000613,CDM,637,RC,,,Outpatient,,,14.94,7.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.99,20,,2.392,Percent of Total Billed Charges,20% of Total Billed Charges,2.99,20,,2.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.99,20,,2.392,Percent of Total Billed Charges,20% of Total Billed Charges,2.99,20,,2.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.71,65,,7.768,Percent of Total Billed Charges,65% of Total Billed Charges,9.71,65,,7.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.99,53.67,
TORSEMIDE TAB [20 MG],3000614,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
traMADol TAB [50 MG],3000618,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
TRANEXAMIC ACID [1000 MG/ 10 ML] SDV,3000619,CDM,636,RC,J3490,HCPCS,Outpatient,,,115.67,57.84,,,,,,Other,Not Seperately Reimbuasble,78.66,68,,62.928,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.13,20,,18.504,Percent of Total Billed Charges,20% of Total Billed Charges,23.13,20,,18.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.13,20,,18.504,Percent of Total Billed Charges,20% of Total Billed Charges,23.13,20,,18.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.54,80,,74.032,Percent of Total Billed Charges,80% of Total Billed Charges,98.32,85,,78.656,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.13,98.32,
traZODone TAB [50 MG],3000620,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
TRIAMCINOLONE [0.5 %] OINTMENT,3000621,CDM,637,RC,,,Outpatient,,,20.81,10.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.16,20,,3.328,Percent of Total Billed Charges,20% of Total Billed Charges,4.16,20,,3.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.16,20,,3.328,Percent of Total Billed Charges,20% of Total Billed Charges,4.16,20,,3.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.53,65,,10.824,Percent of Total Billed Charges,65% of Total Billed Charges,13.53,65,,10.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.16,53.67,
TRIMETHOPRIM TAB [100 MG],3000622,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
TUBERCULIN PPD INJ [5 TU/0.1 ML],3000623,CDM,636,RC,86580,HCPCS,Outpatient,,,47.53,23.77,,30.89,65,,24.712,Percent of Total Billed Charges,65% of Total Billed Charges,32.32,68,,25.856,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.51,20,,7.608,Percent of Total Billed Charges,20% of Total Billed Charges,9.51,20,,7.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.51,20,,7.608,Percent of Total Billed Charges,20% of Total Billed Charges,9.51,20,,7.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.02,80,,30.416,Percent of Total Billed Charges,80% of Total Billed Charges,40.4,85,,32.32,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.51,40.4,
TUCKS MEDICATED PADS,3000624,CDM,637,RC,,,Outpatient,,,19.42,9.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,20,,3.104,Percent of Total Billed Charges,20% of Total Billed Charges,3.88,20,,3.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,20,,3.104,Percent of Total Billed Charges,20% of Total Billed Charges,3.88,20,,3.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,65,,10.096,Percent of Total Billed Charges,65% of Total Billed Charges,12.62,65,,10.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,53.67,
VAC - MODERNA COVID19 VACCINE,3000625,CDM,250,RC,91301,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VAC- HEPATITIS B INJ [20 MCG/ML],3000626,CDM,636,RC,90743,HCPCS,Outpatient,,,307.35,153.68,,199.78,65,,159.824,Percent of Total Billed Charges,65% of Total Billed Charges,209,68,,167.2,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.47,20,,49.176,Percent of Total Billed Charges,20% of Total Billed Charges,61.47,20,,49.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.47,20,,49.176,Percent of Total Billed Charges,20% of Total Billed Charges,61.47,20,,49.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.88,80,,196.704,Percent of Total Billed Charges,80% of Total Billed Charges,261.25,85,,209,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.47,261.25,
VAC- INFLUENZA INJ SYR [0.5 ML],3000627,CDM,636,RC,90686,HCPCS,Outpatient,,,70.4,35.20,,45.76,65,,36.608,Percent of Total Billed Charges,65% of Total Billed Charges,47.87,68,,38.296,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.08,20,,11.264,Percent of Total Billed Charges,20% of Total Billed Charges,14.08,20,,11.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.08,20,,11.264,Percent of Total Billed Charges,20% of Total Billed Charges,14.08,20,,11.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.32,80,,45.056,Percent of Total Billed Charges,80% of Total Billed Charges,59.84,85,,47.872,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.08,59.84,
VAC- PNEUMOCOCCAL 23 INJ [0.5 ML],3000628,CDM,636,RC,90732,HCPCS,Outpatient,,,233.66,116.83,,151.88,65,,121.504,Percent of Total Billed Charges,65% of Total Billed Charges,158.89,68,,127.112,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.73,20,,37.384,Percent of Total Billed Charges,20% of Total Billed Charges,46.73,20,,37.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.73,20,,37.384,Percent of Total Billed Charges,20% of Total Billed Charges,46.73,20,,37.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.93,80,,149.544,Percent of Total Billed Charges,80% of Total Billed Charges,198.61,85,,158.888,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.73,198.61,
VAC- TETANUS DIPH TOX ADULT INJ,3000629,CDM,636,RC,90714,HCPCS,Outpatient,,,170.83,85.42,,111.04,65,,88.832,Percent of Total Billed Charges,65% of Total Billed Charges,116.16,68,,92.928,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.17,20,,27.336,Percent of Total Billed Charges,20% of Total Billed Charges,34.17,20,,27.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.17,20,,27.336,Percent of Total Billed Charges,20% of Total Billed Charges,34.17,20,,27.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.66,80,,109.328,Percent of Total Billed Charges,80% of Total Billed Charges,145.21,85,,116.168,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.17,145.21,
VALPROIC ACID LIQ [250 MG/5 ML],3000630,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
VALSARTAN TAB [160 MG],3000631,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
VANCOMYCIN [ 500 MG ] VIAL,3000632,CDM,636,RC,J3370,HCPCS,Outpatient,,,44.75,22.38,,,,,,Other,Not Seperately Reimbuasble,30.43,68,,24.344,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.95,20,,7.16,Percent of Total Billed Charges,20% of Total Billed Charges,8.95,20,,7.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.95,20,,7.16,Percent of Total Billed Charges,20% of Total Billed Charges,8.95,20,,7.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.8,80,,28.64,Percent of Total Billed Charges,80% of Total Billed Charges,38.04,85,,30.432,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.95,38.04,
VANCOMYCIN [1000 MG] VIAL,3000633,CDM,636,RC,J3370,HCPCS,Outpatient,,,89.25,44.63,,,,,,Other,Not Seperately Reimbuasble,60.69,68,,48.552,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.85,20,,14.28,Percent of Total Billed Charges,20% of Total Billed Charges,17.85,20,,14.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.85,20,,14.28,Percent of Total Billed Charges,20% of Total Billed Charges,17.85,20,,14.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.4,80,,57.12,Percent of Total Billed Charges,80% of Total Billed Charges,75.86,85,,60.688,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.85,75.86,
VANCOMYCIN [1250 MG] VIAL,3000634,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN [1500 MG] VIAL,3000635,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN [750 MG] VIAL,3000636,CDM,636,RC,J3370,HCPCS,Outpatient,,,52.84,26.42,,,,,,Other,Not Seperately Reimbuasble,35.93,68,,28.744,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.57,20,,8.456,Percent of Total Billed Charges,20% of Total Billed Charges,10.57,20,,8.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.57,20,,8.456,Percent of Total Billed Charges,20% of Total Billed Charges,10.57,20,,8.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.27,80,,33.816,Percent of Total Billed Charges,80% of Total Billed Charges,44.91,85,,35.928,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.57,44.91,
VANCOMYCIN CONSULT,3000637,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN HCL CAP [125 MG],3000638,CDM,637,RC,,,Outpatient,,,161.25,80.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.25,20,,25.8,Percent of Total Billed Charges,20% of Total Billed Charges,32.25,20,,25.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.25,20,,25.8,Percent of Total Billed Charges,20% of Total Billed Charges,32.25,20,,25.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.81,65,,83.848,Percent of Total Billed Charges,65% of Total Billed Charges,104.81,65,,83.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.25,104.81,
VASOPRESSIN INJ [20 UNT/ML],3000639,CDM,636,RC,J2598,HCPCS,Outpatient,,,732.59,366.30,,476.18,65,,380.944,Percent of Total Billed Charges,65% of Total Billed Charges,498.16,68,,398.528,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.52,20,,117.216,Percent of Total Billed Charges,20% of Total Billed Charges,146.52,20,,117.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.52,20,,117.216,Percent of Total Billed Charges,20% of Total Billed Charges,146.52,20,,117.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,586.07,80,,468.856,Percent of Total Billed Charges,80% of Total Billed Charges,622.7,85,,498.16,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.52,622.7,
VECURONIUM BROMIDE INJ [10 MG/ML],3000640,CDM,250,RC,,,Outpatient,,,44.5,22.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.9,20,,7.12,Percent of Total Billed Charges,20% of Total Billed Charges,8.9,20,,7.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.9,20,,7.12,Percent of Total Billed Charges,20% of Total Billed Charges,8.9,20,,7.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.93,65,,23.144,Percent of Total Billed Charges,65% of Total Billed Charges,28.93,65,,23.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.9,53.67,
VENLAFAXINE XR CAP  [150 MG],3000641,CDM,637,RC,,,Outpatient,,,23.59,11.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.72,20,,3.776,Percent of Total Billed Charges,20% of Total Billed Charges,4.72,20,,3.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.72,20,,3.776,Percent of Total Billed Charges,20% of Total Billed Charges,4.72,20,,3.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,65,,12.264,Percent of Total Billed Charges,65% of Total Billed Charges,15.33,65,,12.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.72,53.67,
VENLAFAXINE XR CAP [37.5 MG],3000642,CDM,637,RC,,,Outpatient,,,21.48,10.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.3,20,,3.44,Percent of Total Billed Charges,20% of Total Billed Charges,4.3,20,,3.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.3,20,,3.44,Percent of Total Billed Charges,20% of Total Billed Charges,4.3,20,,3.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.96,65,,11.168,Percent of Total Billed Charges,65% of Total Billed Charges,13.96,65,,11.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.3,53.67,
VENLAFAXINE XR CAP [75 MG],3000643,CDM,637,RC,,,Outpatient,,,24.05,12.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.81,20,,3.848,Percent of Total Billed Charges,20% of Total Billed Charges,4.81,20,,3.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.81,20,,3.848,Percent of Total Billed Charges,20% of Total Billed Charges,4.81,20,,3.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.63,65,,12.504,Percent of Total Billed Charges,65% of Total Billed Charges,15.63,65,,12.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.81,53.67,
VERAPAMIL INJ [5 MG/ 2 ML],3000644,CDM,636,RC,,,Outpatient,,,57.94,28.97,,,,,,Other,Not Seperately Reimbuasble,39.4,68,,31.52,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.59,20,,9.272,Percent of Total Billed Charges,20% of Total Billed Charges,11.59,20,,9.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.59,20,,9.272,Percent of Total Billed Charges,20% of Total Billed Charges,11.59,20,,9.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,80,,37.08,Percent of Total Billed Charges,80% of Total Billed Charges,49.25,85,,39.4,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.59,49.25,
VIT- B-1 INJ [200 MG/2 ML],3000645,CDM,636,RC,J3411,HCPCS,Outpatient,,,27.71,13.86,,,,,,Other,Not Seperately Reimbuasble,18.84,68,,15.072,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,20,,4.432,Percent of Total Billed Charges,20% of Total Billed Charges,5.54,20,,4.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,20,,4.432,Percent of Total Billed Charges,20% of Total Billed Charges,5.54,20,,4.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.17,80,,17.736,Percent of Total Billed Charges,80% of Total Billed Charges,23.55,85,,18.84,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,23.55,
VIT- B-12 INJ [1000 MCG/ML],3000646,CDM,636,RC,J3420,HCPCS,Outpatient,,,38.52,19.26,,,,,,Other,Not Seperately Reimbuasble,26.19,68,,20.952,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.7,20,,6.16,Percent of Total Billed Charges,20% of Total Billed Charges,7.7,20,,6.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.7,20,,6.16,Percent of Total Billed Charges,20% of Total Billed Charges,7.7,20,,6.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.82,80,,24.656,Percent of Total Billed Charges,80% of Total Billed Charges,32.74,85,,26.192,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.7,32.74,
VITAMIN  B-1 TAB [100 MG],3000647,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
VITAMIN A & D OINT,3000648,CDM,250,RC,,,Outpatient,,,6.64,3.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,20,,1.064,Percent of Total Billed Charges,20% of Total Billed Charges,1.33,20,,1.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,20,,1.064,Percent of Total Billed Charges,20% of Total Billed Charges,1.33,20,,1.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.32,65,,3.456,Percent of Total Billed Charges,65% of Total Billed Charges,4.32,65,,3.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,53.67,
VITAMIN- B-12 TAB [500 MCG],3000649,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
VITAMIN- B-6 TAB [50 MG],3000650,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
VITAMIN- C TAB [500 MG],3000651,CDM,637,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
"VITAMIN- D3 [1,000 IU/25 MCG]",3000652,CDM,250,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
"VITAMIN- D3 [5,000 IU/125 MCG]",3000653,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
VITAMIN- K [1 MG/0.5 ML] INJ,3000654,CDM,636,RC,J3430,HCPCS,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,80,,16.48,Percent of Total Billed Charges,80% of Total Billed Charges,21.89,85,,17.512,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,21.89,
VITAMIN- K [10 MG/ML] INJ,3000655,CDM,636,RC,J3430,HCPCS,Outpatient,,,237.88,118.94,,,,,,Other,Not Seperately Reimbuasble,161.76,68,,129.408,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.58,20,,38.064,Percent of Total Billed Charges,20% of Total Billed Charges,47.58,20,,38.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.58,20,,38.064,Percent of Total Billed Charges,20% of Total Billed Charges,47.58,20,,38.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.3,80,,152.24,Percent of Total Billed Charges,80% of Total Billed Charges,202.2,85,,161.76,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.58,202.2,
WOUND CARE - SANTYL,3000656,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ZINC OXIDE [11.3 %] CREAM,3000657,CDM,250,RC,,,Outpatient,,,13.8,6.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,20,,2.208,Percent of Total Billed Charges,20% of Total Billed Charges,2.76,20,,2.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,20,,2.208,Percent of Total Billed Charges,20% of Total Billed Charges,2.76,20,,2.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.97,65,,7.176,Percent of Total Billed Charges,65% of Total Billed Charges,8.97,65,,7.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,53.67,
ZINC OXIDE [20 %] OINT,3000658,CDM,637,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
ZINC SULFATE CAP [220 MG],3000659,CDM,637,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
ZIPRASIDONE HCL CAP [20 MG],3000660,CDM,637,RC,,,Outpatient,,,45.68,22.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.14,20,,7.312,Percent of Total Billed Charges,20% of Total Billed Charges,9.14,20,,7.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.14,20,,7.312,Percent of Total Billed Charges,20% of Total Billed Charges,9.14,20,,7.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.69,65,,23.752,Percent of Total Billed Charges,65% of Total Billed Charges,29.69,65,,23.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.14,53.67,
ZOLPIDEM TAB [5 MG],3000661,CDM,637,RC,,,Outpatient,,,41.41,20.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.28,20,,6.624,Percent of Total Billed Charges,20% of Total Billed Charges,8.28,20,,6.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.28,20,,6.624,Percent of Total Billed Charges,20% of Total Billed Charges,8.28,20,,6.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.92,65,,21.536,Percent of Total Billed Charges,65% of Total Billed Charges,26.92,65,,21.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.28,53.67,
INF- AMIODARONE/D5W IVPB : 150MG/100ML,3060700,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- AMIODARONE/D5W IVPB : 450MG/250ML,3060701,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AMPICILLIN/NS IVPB : 1000MG/100ML,3060702,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AMPICILLIN/NS IVPB : 500MG/50ML,3060703,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AMPICILLIN-SULB/NS IVPB : 3000MG/100ML,3060704,CDM,258,RC,J0295,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AZITHROMYCIN/NS IVPB : 500MG/250ML,3060705,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IVF-BANANA BAG 1000ML [NS],3060706,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALCIUM CL 10%/NS IVPB : 10ML/100ML,3060707,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALCIUM GLUCONATE/NS IVPB : [3GM/100ML],3060708,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CASIRIVIMAB-IMDEV/NS IVPB : 600MG/100ML,3060709,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ceFAZolin/NS IVPB : 1000MG/100ML,3060710,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CEFEPIME/NS IVPB : 1000MG/50ML,3060711,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
cefTRIAXone/NS IVPB : 1000MG/50ML,3060712,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
cefTRIAXone/NS IVPB : 2000MG/100ML,3060713,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
cefTRIAXone/NS IVPB : 250MG/50ML,3060714,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
cefTRIAXone/NS IVPB : 500MG/50ML,3060715,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLINDAMYCIN/NS IVPB : 600MG/50ML,3060716,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLINDAMYCIN/NS IVPB : 900MG/100ML,3060717,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF-CROTALIDAE POLY/NS IVPB:2VIALS/250ML,3060718,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DAPTOmycin/NS IVPB : 500MG/50ML,3060719,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DEXTROSE 10%/NS IVPB : 25GM/250ML,3060720,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DEXTROSE 10%/NS IVPB : 5 GM/50ML,3060721,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- DILTIAZEM/NS IVPB : 125MG/125ML,3060722,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DOXYCYCLINE/NS IVPB : 100MG/250ML,3060723,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENALAPRILAT/NS IVPB : 1.25MG/50ML,3060724,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- EPINEPHRINE/NS IVPB : 1MG/250ML,3060725,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ERTAPENEM/NS IVPB : 1000MG/50ML,3060726,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- FENTANYL/NS IVPB : 500MCG/50ML,3060727,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GENTAMICIN/NS IVPB : 80MG/100ML,3060728,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IMIPENEM-CILAST/NS IVPB : 250MG/100ML,3060729,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IMIPENEM-CILAST/NS IVPB : 500MG/100ML,3060730,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INSULIN R/NS IVPB : 50UNITS/500ML,3060731,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IRON SUCROSE/NS IVPB : 200MG/100ML,3060732,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- KETAMINE/NS IVPB : 500MG/250ML,3060733,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- KETAMINE/NS IVPB : 500MG/500ML,3060734,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LEVETIRACETAM/NS IVPB : 500MG/100ML,3060735,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MEROPENEM/NS IVPB : 1000MG/50ML,3060736,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MEROPENEM/NS IVPB : 500MG/50ML,3060737,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- MIDAZOLAM/NS IVPB : 25MG/100ML,3060738,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NAFCILLIN/NS IVPB : 1000MG/100ML,3060739,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- NICARDIPINE/NS IVPB : 25MG/250ML,3060740,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- NITROPRUSSIDE/D5W IVPB : 50MG/250ML,3060741,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- NOREPINEPHRINE/D5W IVPB : 2MG/250ML,3060742,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- OCTREOTIDE/NS IVPB : 200MCG/200ML,3060743,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OCTREOTIDE/NS IVPB : 50MCG/50ML,3060744,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- OXYTOCIN/NS IVPB : 10UNITS/1000ML,3060745,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PANTOPRAZOLE/NS IVPB : 40MG/100ML,3060746,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- PHENYLEPHRINE/NS IVPB : 10MG/500ML,3060747,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPERACILLIN-TAZ/NS IVPB : 2.25GM/100ML,3060748,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPERACILLIN-TAZ/NS IVPB : 4.5GM/100ML,3060749,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPERACILL-TAZO/NS IVPB : 3.375GM/100ML,3060750,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PROMETHAZINE/NS IVPB : 25MG/1000ML,3060751,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PROMETHAZINE/NS IVPB : 25MG/50ML,3060752,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REMDESIVIR/NS IVPB : 100MG/250ML,3060753,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SODIUM BICARBONAT/NS IVPB : 10MEQ/1000ML,3060754,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SODIUM BICARBONATE/NS IVPB : 10MEQ/500ML,3060755,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF-SULFAMETH-TMP/D5W IVPB : 800MG/250ML,3060756,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF-TOCILIZUMAB/NS IVPB : 200MG/100ML,3060757,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF-TRANEXAMIC ACID/NS IVPB:1000MG/100ML,3060758,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN/NS IVPB : 1000MG/250ML,3060759,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN/NS IVPB : 1250MG/250ML,3060760,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN/NS IVPB : 1500MG/250ML,3060761,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN/NS IVPB : 1GM/250ML,3060762,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN/NS IVPB : 1GM/500ML,3060763,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN/NS IVPB : 500MG/250ML,3060764,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN/NS IVPB : 750MG/250ML,3060765,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- VASOPRESSIN/NS IVPB: 50 UNITS/500ML,3060766,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-FISH OIL AVPAK 1000MG-3IU,3060768,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-1-Butanol Liquid,3060771,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TYLENOL ORAL TABLET 325MG,3060774,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3060775,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EMPAGLIFLOZIN TAB [10 MG],3060776,CDM,250,RC,,,Outpatient,,,34.08,17.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.82,20,,5.456,Percent of Total Billed Charges,20% of Total Billed Charges,6.82,20,,5.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.82,20,,5.456,Percent of Total Billed Charges,20% of Total Billed Charges,6.82,20,,5.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.15,65,,17.72,Percent of Total Billed Charges,65% of Total Billed Charges,22.15,65,,17.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.82,53.67,
NF-Jardiance Oral Tablet 25MG,3060777,CDM,250,RC,,,Outpatient,,,70.04,35.02,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,53.67,
ALTEPLASE - tPA [100 MG] IV,3060778,CDM,636,RC,J2997,HCPCS,Outpatient,,,13639.11,6819.56,,8865.42,65,,7092.336,Percent of Total Billed Charges,65% of Total Billed Charges,9274.59,68,,7419.672,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2727.82,20,,2182.256,Percent of Total Billed Charges,20% of Total Billed Charges,2727.82,20,,2182.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2727.82,20,,2182.256,Percent of Total Billed Charges,20% of Total Billed Charges,2727.82,20,,2182.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10911.29,80,,8729.032,Percent of Total Billed Charges,80% of Total Billed Charges,11593.24,85,,9274.592,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2727.82,11593.24,
NF-Diovan Oral Tablet 80MG,3060779,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
VIOKASE INSTRUCTIONS CONTINUED,3060780,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Nutren 2.0 Liquid,3060781,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WOUND CARE - ANTICOAT 7,3060782,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LIDOCAINE/EPI/TETRA TOPICAL GEL (L.E.T.),3060785,CDM,250,RC,,,Outpatient,,,62.52,31.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,20,,10,Percent of Total Billed Charges,20% of Total Billed Charges,12.5,20,,10,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,20,,10,Percent of Total Billed Charges,20% of Total Billed Charges,12.5,20,,10,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.64,65,,32.512,Percent of Total Billed Charges,65% of Total Billed Charges,40.64,65,,32.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,53.67,
CENTRAL LINE CARE - NS COMMUNICATION,3060786,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HEEL FLOAT -NURSING EVALUTION,3060787,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OCCULT BLOOD - STOOL - NS REMINDER,3060788,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HEATING THERAPY - NURSING COMMUNICATION,3060789,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEURO CHECKS - NURSING EVALUATIONS,3060790,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PICC LINE STERILE DRESSING CHANGE,3060791,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WOUND CARE - DAKIN'S,3060792,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WOUND CARE - NON-MEDICATED,3060793,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WOUND CARE - PROMOGRAM DRESSING,3060794,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WOUND CARE - SILVADENE,3060795,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WOUND CARE - TAO,3060796,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WOUND CARE - THERAHONEY GEL,3060797,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Lantus SoloStar Pen SubQ Soln 100U/1M,3060801,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DAILY D-DIMER,3060802,CDM,305,RC,85378,HCPCS,Outpatient,,,141,70.50,,91.65,65,,73.32,Percent of Total Billed Charges,65% of Total Billed Charges,95.88,68,,76.704,Percent of Total Billed Charges,68% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,28.2,20,,22.56,Percent of Total Billed Charges,20% of Total Billed Charges,28.2,20,,22.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.2,20,,22.56,Percent of Total Billed Charges,20% of Total Billed Charges,28.2,20,,22.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.65,65,,73.32,Percent of Total Billed Charges,65% of Total Billed Charges,91.65,65,,73.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.12,95.88,
DAILY FERRITIN,3060803,CDM,301,RC,82728,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,19.33,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
DAILY PT/INR,3060805,CDM,305,RC,85610,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,5.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.58,42.02,
CEFEPIME /NS IVPB: 2000MG/100ML,3060809,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Cefepime Intravenous Solution 2GM/100,3060810,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Cefepime Intravenous Solution 2GM/100,3060811,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Cefepime Intravenous Solution 2GM/100,3060812,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
CEFEPIME [2000 MG] VIAL,3060813,CDM,250,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
NF-Valsartan/HCTZ [320/25 MG],3060817,CDM,250,RC,,,Outpatient,,,18.54,9.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,20,,2.968,Percent of Total Billed Charges,20% of Total Billed Charges,3.71,20,,2.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,20,,2.968,Percent of Total Billed Charges,20% of Total Billed Charges,3.71,20,,2.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,65,,9.64,Percent of Total Billed Charges,65% of Total Billed Charges,12.05,65,,9.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,53.67,
NF-Cyproheptadine Hydrochloride Tablet 4,3060818,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Olopatadine HCl Ophthalmic Solution 0,3060820,CDM,250,RC,,,Outpatient,,,221.45,110.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.29,20,,35.432,Percent of Total Billed Charges,20% of Total Billed Charges,44.29,20,,35.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.29,20,,35.432,Percent of Total Billed Charges,20% of Total Billed Charges,44.29,20,,35.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.94,65,,115.152,Percent of Total Billed Charges,65% of Total Billed Charges,143.94,65,,115.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.29,143.94,
NF-Alka-Seltzer Heartburn Relief 750MG,3060821,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Myrbetriq Oral Tablet ER 25MG,3060823,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NURSING COMMUNICATION - GENERAL,3060825,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Simvastatin Oral Tablet 20MG,3060828,CDM,250,RC,,,Outpatient,,,14.42,7.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,53.67,
NF-Simvastatin Oral Tablet 20MG,3060829,CDM,250,RC,,,Outpatient,,,14.42,7.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,53.67,
"NF-Vitamin D Capsule 50,000IU",3060830,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Colestipol Hydrochloride Oral Tablet,3060832,CDM,250,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
NF-Diclofenac Sodium AvPak Topical Gel 1,3060833,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Drisdol Oral LiquidFilledCapsule 5000,3060834,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
NF-guaiFENesin Oral Solution 100MG/5ML,3060835,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Promethazine HCl Oral Tablet 12.5MG,3060836,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
Lidocaine Topical Ointment 5% -NF,3060837,CDM,250,RC,,,Outpatient,,,39.24,19.62,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.85,20,,6.28,Percent of Total Billed Charges,20% of Total Billed Charges,7.85,20,,6.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.85,20,,6.28,Percent of Total Billed Charges,20% of Total Billed Charges,7.85,20,,6.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.51,65,,20.408,Percent of Total Billed Charges,65% of Total Billed Charges,25.51,65,,20.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.85,53.67,
NF-Linzess Oral Capsule 145MCG,3060838,CDM,250,RC,,,Outpatient,,,59.74,29.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,53.67,
NF-Linzess Oral Capsule 145MCG,3060840,CDM,250,RC,,,Outpatient,,,59.74,29.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,53.67,
NF-Diclofenac Sodium Topical Gel 1%,3060841,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Omeprazole Delayed-Release Capsule 20,3060842,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
NF-Fenofibrate Oral Tablet 48MG,3060843,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
NF-Vitamin D3 Oral Cap 125MCG,3060844,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Sodium Chloride Ophthalmic Ointment 5,3060845,CDM,250,RC,,,Outpatient,,,15.45,7.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,53.67,
AZELASTINE NASAL [137MCG/SPRAY]-(NF),3060846,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
NF-Azelastine HCl Nasal Spray 137MCG/1Ac,3060848,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3060851,CDM,250,RC,,,Outpatient,,,460.41,230.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.08,20,,73.664,Percent of Total Billed Charges,20% of Total Billed Charges,92.08,20,,73.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.08,20,,73.664,Percent of Total Billed Charges,20% of Total Billed Charges,92.08,20,,73.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,299.27,65,,239.416,Percent of Total Billed Charges,65% of Total Billed Charges,299.27,65,,239.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,299.27,
NF-Diclofenac Sodium Topical Gel 1%,3060852,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Methocarbamol Tablet 750MG,3060853,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Methocarbamol Tablet 750MG,3060854,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Glucerna 1.5 Cal Oral Suspension,3060855,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Pantoprazole Sodium DR Pkt 40MG,3060856,CDM,250,RC,,,Outpatient,,,51.5,25.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,53.67,
NF-Pro-Stat Sugar Free Liquid,3060857,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Urocit-K Tablet 10MEQ,3060860,CDM,250,RC,,,Outpatient,,,7.21,3.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,53.67,
HYDROCORTISONE RECTAL SUSP [100 MG/60ML],3060861,CDM,637,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HYDROCORTISONE RECTAL SUSP [100 MG/60ML],3060863,CDM,637,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SODIUM BICARBONATE(50 mEq/1000ML)1/2 NS,3060864,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SODIUM BICARB INJ *VIAL* [50 MEQ/50 ML],3060866,CDM,250,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
NF-valACYclovir Hydrochloride Oral Tab 1,3060867,CDM,250,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
NF-valACYclovir Hydrochloride Oral Tab 1,3060869,CDM,250,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
PSYLLIUM ORAL PACKET [5.8 GM] SUGAR FREE,3060870,CDM,250,RC,,,Outpatient,,,2.83,1.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,20,,0.456,Percent of Total Billed Charges,20% of Total Billed Charges,0.57,20,,0.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,20,,0.456,Percent of Total Billed Charges,20% of Total Billed Charges,0.57,20,,0.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,65,,1.472,Percent of Total Billed Charges,65% of Total Billed Charges,1.84,65,,1.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,53.67,
NF-Advair Diskus 250/50 Disk,3060871,CDM,250,RC,,,Outpatient,,,23.69,11.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,53.67,
NF-Azelastine HCl Nasal Spray 137MCG/1IN,3060877,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
LINEZOLID ORAL TABLET 600MG,3060878,CDM,250,RC,,,Outpatient,,,23.3,11.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.66,20,,3.728,Percent of Total Billed Charges,20% of Total Billed Charges,4.66,20,,3.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.66,20,,3.728,Percent of Total Billed Charges,20% of Total Billed Charges,4.66,20,,3.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.15,65,,12.12,Percent of Total Billed Charges,65% of Total Billed Charges,15.15,65,,12.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.66,53.67,
TRESIBA FLEXTOUCH PEN[200 UNITS/ML]-(NF),3060879,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MORPHINE ORAL TAB ER [15 MG],3060882,CDM,637,RC,,,Outpatient,,,7.98,3.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,5.19,65,,4.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
NF-Azelastine HCl Nasal Spray 137MCG/1AC,3060883,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
NF-Entresto Oral Tablet 24MG-26MG,3060884,CDM,250,RC,,,Outpatient,,,39.14,19.57,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.83,20,,6.264,Percent of Total Billed Charges,20% of Total Billed Charges,7.83,20,,6.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.83,20,,6.264,Percent of Total Billed Charges,20% of Total Billed Charges,7.83,20,,6.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.44,65,,20.352,Percent of Total Billed Charges,65% of Total Billed Charges,25.44,65,,20.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.83,53.67,
TRELEGY ELLIPTA INH[100/62.5/25MCG]-(NF),3060887,CDM,250,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
NF-Opsumit Oral Tablet 10MG,3060890,CDM,250,RC,,,Outpatient,,,1382.26,691.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,276.45,20,,221.16,Percent of Total Billed Charges,20% of Total Billed Charges,276.45,20,,221.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,276.45,20,,221.16,Percent of Total Billed Charges,20% of Total Billed Charges,276.45,20,,221.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,898.47,65,,718.776,Percent of Total Billed Charges,65% of Total Billed Charges,898.47,65,,718.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,898.47,
NF-Sildenafil AvPak Oral Tablet 20MG,3060893,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Ofev Oral Capsule 150MG,3060894,CDM,250,RC,,,Outpatient,,,727.18,363.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.44,20,,116.352,Percent of Total Billed Charges,20% of Total Billed Charges,145.44,20,,116.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.44,20,,116.352,Percent of Total Billed Charges,20% of Total Billed Charges,145.44,20,,116.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.67,65,,378.136,Percent of Total Billed Charges,65% of Total Billed Charges,472.67,65,,378.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,472.67,
NF-Anastrozole Oral Tablet 1MG,3060895,CDM,250,RC,,,Outpatient,,,41.2,20.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,53.67,
NF-Advair Diskus 500/50 Disk,3060898,CDM,250,RC,,,Outpatient,,,31.93,15.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.75,65,,16.6,Percent of Total Billed Charges,65% of Total Billed Charges,20.75,65,,16.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,53.67,
NF-cycloSPORINE Ophth Emulsion 0.05%,3060899,CDM,250,RC,,,Outpatient,,,37.08,18.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,53.67,
NF-Tresiba FlexTouch Pen SubQ Soln 200U/,3060900,CDM,250,RC,,,Outpatient,,,251.32,125.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.36,65,,130.688,Percent of Total Billed Charges,65% of Total Billed Charges,163.36,65,,130.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,163.36,
AMPICILLIN [2000 MG] IM INJ,3060902,CDM,250,RC,J0290,HCPCS,Outpatient,,,26.68,13.34,,17.34,65,,13.872,Percent of Total Billed Charges,65% of Total Billed Charges,18.14,68,,14.512,Percent of Total Billed Charges,68% of Total Billed Charges,1.86,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,5.34,20,,4.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.34,65,,13.872,Percent of Total Billed Charges,65% of Total Billed Charges,17.34,65,,13.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.86,53.67,
VICTOZA SUBQ SOL [6MG/1ML]- (NF),3060903,CDM,250,RC,,,Outpatient,,,437.75,218.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.54,65,,227.632,Percent of Total Billed Charges,65% of Total Billed Charges,284.54,65,,227.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,284.54,
NF-cycloSPORINE Ophth Emulsion 0.05%,3060907,CDM,250,RC,,,Outpatient,,,37.08,18.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,53.67,
Testosterone Topical Gel 1.62% -NF,3060908,CDM,250,RC,,,Outpatient,,,242.15,121.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.43,20,,38.744,Percent of Total Billed Charges,20% of Total Billed Charges,48.43,20,,38.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.43,20,,38.744,Percent of Total Billed Charges,20% of Total Billed Charges,48.43,20,,38.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.4,65,,125.92,Percent of Total Billed Charges,65% of Total Billed Charges,157.4,65,,125.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.43,157.4,
NF-Vitamin D Oral Capsule 50000IU,3060909,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Tresiba FlexTouch Pen SubQ Soln 200U/,3060910,CDM,250,RC,,,Outpatient,,,251.32,125.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.36,65,,130.688,Percent of Total Billed Charges,65% of Total Billed Charges,163.36,65,,130.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,163.36,
NF-Symbicort Inh Aer Liq 160MCG-4.5MCG,3060911,CDM,250,RC,,,Outpatient,,,136.99,68.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.04,65,,71.232,Percent of Total Billed Charges,65% of Total Billed Charges,89.04,65,,71.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,89.04,
NF-Dulera Inh Aer Pwd 5MCG-200MCG/Act,3060912,CDM,250,RC,,,Outpatient,,,88.58,44.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.72,20,,14.176,Percent of Total Billed Charges,20% of Total Billed Charges,17.72,20,,14.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.72,20,,14.176,Percent of Total Billed Charges,20% of Total Billed Charges,17.72,20,,14.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.58,65,,46.064,Percent of Total Billed Charges,65% of Total Billed Charges,57.58,65,,46.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.72,57.58,
NF-Invokana Oral Tablet 100MG,3060913,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Janumet Oral Tablet 50MG-1000MG,3060914,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"NF-Vitamin D Capsule 50,000IU",3060915,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Victoza Subcutaneous Solution 6MG/1ML,3060920,CDM,250,RC,,,Outpatient,,,437.75,218.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.54,65,,227.632,Percent of Total Billed Charges,65% of Total Billed Charges,284.54,65,,227.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,284.54,
HYDROCORTISONE RECTAL SUSP [100 MG/60ML],3060923,CDM,637,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Symbicort Inh Aer Liq 160MCG-4.5MCG,3060924,CDM,250,RC,,,Outpatient,,,136.99,68.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.04,65,,71.232,Percent of Total Billed Charges,65% of Total Billed Charges,89.04,65,,71.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,89.04,
NF-Turmeric Oral Capsule 500MG,3060925,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Losartan/Hctz Oral Tablet 50MG-12.5MG,3060927,CDM,250,RC,,,Outpatient,,,7.21,3.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,53.67,
NF-Tresiba FlexTouch Pen SubQ Soln 200U/,3060928,CDM,250,RC,,,Outpatient,,,251.32,125.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,50.26,20,,40.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.36,65,,130.688,Percent of Total Billed Charges,65% of Total Billed Charges,163.36,65,,130.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.26,163.36,
NF-Omeprazole Delayed-Release Capsule 20,3060929,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
"NF-Vitamin D Capsule 50,000IU",3060931,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Abilify Oral Tablet 2MG,3060932,CDM,250,RC,,,Outpatient,,,72.1,36.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,53.67,
NF-Etonogestrel/Ethinyl Estradiol,3060933,CDM,250,RC,,,Outpatient,,,566.5,283.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.3,20,,90.64,Percent of Total Billed Charges,20% of Total Billed Charges,113.3,20,,90.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.3,20,,90.64,Percent of Total Billed Charges,20% of Total Billed Charges,113.3,20,,90.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.23,65,,294.584,Percent of Total Billed Charges,65% of Total Billed Charges,368.23,65,,294.584,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,368.23,
NF-Vitamin B12 Tablet 5000mcg,3060935,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vitamin D3 Oral Liq Cap 125MCG,3060936,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Citracal Petites Oral Tablet 200MG-25,3060937,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"NF-Vitamin D Capsule 50,000IU",3060939,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FLUTIC/SALMETEROL [250/50 MCG] DISK-(NF),3060940,CDM,250,RC,,,Outpatient,,,23.69,11.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,53.67,
NF-Vitamin D3 Oral Cap 125MCG,3060941,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Prolensa Ophthalmic Solution 0.07%,3060942,CDM,250,RC,,,Outpatient,,,392.43,196.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.49,20,,62.792,Percent of Total Billed Charges,20% of Total Billed Charges,78.49,20,,62.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.49,20,,62.792,Percent of Total Billed Charges,20% of Total Billed Charges,78.49,20,,62.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.08,65,,204.064,Percent of Total Billed Charges,65% of Total Billed Charges,255.08,65,,204.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,255.08,
NF-Lotemax SM Ophthalmic Gel 0.38%,3060943,CDM,250,RC,,,Outpatient,,,167.89,83.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.58,20,,26.864,Percent of Total Billed Charges,20% of Total Billed Charges,33.58,20,,26.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.58,20,,26.864,Percent of Total Billed Charges,20% of Total Billed Charges,33.58,20,,26.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.13,65,,87.304,Percent of Total Billed Charges,65% of Total Billed Charges,109.13,65,,87.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.58,109.13,
NF-Lotemax SM Ophthalmic Gel 0.38%,3060944,CDM,250,RC,,,Outpatient,,,167.89,83.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.58,20,,26.864,Percent of Total Billed Charges,20% of Total Billed Charges,33.58,20,,26.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.58,20,,26.864,Percent of Total Billed Charges,20% of Total Billed Charges,33.58,20,,26.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.13,65,,87.304,Percent of Total Billed Charges,65% of Total Billed Charges,109.13,65,,87.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.58,109.13,
REMDESIVIR/NS IVPB : 200MG/250ML,3060945,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-ALPRAZolam Extended-Release Tablet 1M,3060946,CDM,250,RC,,,Outpatient,,,7.21,3.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,53.67,
NF-amLODIPine & Benazepril HCl 10MG-20MG,3060947,CDM,250,RC,,,Outpatient,,,9.27,4.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,65,,4.824,Percent of Total Billed Charges,65% of Total Billed Charges,6.03,65,,4.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,53.67,
NF-Omeprazole Capsule Delayed Release 40,3060949,CDM,250,RC,,,Outpatient,,,22.66,11.33,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,53.67,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3060951,CDM,250,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
NF-Farxiga Oral Tablet 5MG,3060955,CDM,250,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
LINZESS (LinaCLOtide) CAP [145MCG]- (NF),3060958,CDM,250,RC,,,Outpatient,,,59.74,29.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,53.67,
NF-Levocetirizine Dihydrochloride Tab 5M,3060959,CDM,250,RC,,,Outpatient,,,9.27,4.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,65,,4.824,Percent of Total Billed Charges,65% of Total Billed Charges,6.03,65,,4.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,53.67,
NF-Advanced Sleep Melatonin Tab ER 10MG,3060960,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-aMILoride HCl Oral Tablet 5MG,3060961,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Advanced Sleep Melatonin Tab ER 10MG,3060962,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-aMILoride HCl Oral Tablet 5MG,3060963,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Levocetirizine DiHCl Oral Tablet 5MG,3060964,CDM,250,RC,,,Outpatient,,,9.27,4.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,65,,4.824,Percent of Total Billed Charges,65% of Total Billed Charges,6.03,65,,4.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,53.67,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3060965,CDM,250,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
NF-Mycophenolate Mofetil Capsule 250MG,3060967,CDM,250,RC,,,Outpatient,,,11.33,5.67,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.36,65,,5.888,Percent of Total Billed Charges,65% of Total Billed Charges,7.36,65,,5.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,53.67,
NF-Tacrolimus Oral Capsule 1MG,3060968,CDM,250,RC,,,Outpatient,,,13.39,6.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,53.67,
NF-Zinc Oral Capsule 50MG,3060969,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-doxazosin Oral Tablet 4MG,3060970,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Tacrolimus Oral Capsule 1MG,3060971,CDM,250,RC,,,Outpatient,,,13.39,6.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,53.67,
NF-Mycophenolate Mofetil Cap 250MG,3060972,CDM,250,RC,,,Outpatient,,,11.33,5.67,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.36,65,,5.888,Percent of Total Billed Charges,65% of Total Billed Charges,7.36,65,,5.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,53.67,
NF-Doxazosin Mesylate Oral Tablet 4MG,3060973,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Doxazosin Mesylate Oral Tablet 4MG,3060976,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-One-A-Day Women's Tablet,3060977,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-ARIPiprazole Oral Tablet 5MG,3060980,CDM,250,RC,,,Outpatient,,,98.88,49.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,64.27,
NF-Linzess Oral Capsule 145MCG,3060981,CDM,250,RC,,,Outpatient,,,59.74,29.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,53.67,
SODIUM BICARBONATE (75 mEq/1000ML)1/2 NS,3060982,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SODIUM BICARB 100 mEq/1000ML) D5W,3060983,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Trulance Oral Tablet 3MG,3060987,CDM,250,RC,,,Outpatient,,,61.8,30.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
NF-tiaGABine Hydrochloride Oral Tablet 4,3060988,CDM,250,RC,,,Outpatient,,,23.69,11.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,53.67,
FARXIGA TAB  [5 MG]- (NF),3060989,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Toujeo SubQ Solution 300U/1ML,3060990,CDM,250,RC,,,Outpatient,,,319.3,159.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.86,20,,51.088,Percent of Total Billed Charges,20% of Total Billed Charges,63.86,20,,51.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.86,20,,51.088,Percent of Total Billed Charges,20% of Total Billed Charges,63.86,20,,51.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.55,65,,166.04,Percent of Total Billed Charges,65% of Total Billed Charges,207.55,65,,166.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,207.55,
NF-Farxiga Oral Tablet 5MG,3060991,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Toujeo SubQ Solution 300U/1ML,3060992,CDM,250,RC,,,Outpatient,,,319.3,159.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.86,20,,51.088,Percent of Total Billed Charges,20% of Total Billed Charges,63.86,20,,51.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.86,20,,51.088,Percent of Total Billed Charges,20% of Total Billed Charges,63.86,20,,51.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.55,65,,166.04,Percent of Total Billed Charges,65% of Total Billed Charges,207.55,65,,166.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,207.55,
NF-rivastigmine TD Patch ER 13.3MG/24HR,3060993,CDM,250,RC,,,Outpatient,,,49.44,24.72,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,53.67,
DILTIAZEM HCL INJ[125 MG/25ML] SDV,3060995,CDM,250,RC,,,Outpatient,,,25.75,12.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,53.67,
NF-SUMAtriptan Oral Tablet 50MG,3060998,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"NF-Vitamin D Capsule 50,000IU",3061001,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Haloperidol Tablet 0.5MG,3061002,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Hyoscyamine Sulfate Oral Tablet 0.125,3061003,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Loperamide Oral Tablet 2MG,3061004,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NovoLOG FlexPen SQ Soln 100U/ML-NF,3061005,CDM,250,RC,,,Outpatient,,,138.02,69.01,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.71,65,,71.768,Percent of Total Billed Charges,65% of Total Billed Charges,89.71,65,,71.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.6,89.71,
TESTOSTERONE CYPIONATE IM 200MG/1ML-NF,3061006,CDM,250,RC,,,Outpatient,,,65.92,32.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.85,65,,34.28,Percent of Total Billed Charges,65% of Total Billed Charges,42.85,65,,34.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,53.67,
NF-Ozempic 0.25MG or 0.5MG Doses 2MG/1.5,3061008,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Ramipril Oral Capsule 1.25MG,3061009,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Artificial Tears Ophth Solution,3061011,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Dorzolamide HCl-Timolol 22.3MG-6.8MG/,3061012,CDM,250,RC,,,Outpatient,,,37.08,18.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,53.67,
NF-Systane Lubricant Eye Drops 0.4%-0.3%,3061013,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Travoprost Ophthalmic Solution 0.004%,3061014,CDM,250,RC,,,Outpatient,,,255.44,127.72,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.09,20,,40.872,Percent of Total Billed Charges,20% of Total Billed Charges,51.09,20,,40.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.09,20,,40.872,Percent of Total Billed Charges,20% of Total Billed Charges,51.09,20,,40.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.04,65,,132.832,Percent of Total Billed Charges,65% of Total Billed Charges,166.04,65,,132.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.09,166.04,
FAMOTIDINE/NS IVPB [20MG/100ML],3061017,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF- KETAMINE/NS IVPB : 250MG/250ML,3061018,CDM,361,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF-SODIUM BICARB (50mEq/1000ML)D5-1/2NS,3061019,CDM,361,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IVF-BANANA BAG 1000ML [D5W],3061020,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MANNITOL INJ 20% PREMIX [500 ML],3061022,CDM,258,RC,,,Outpatient,,,0.14,0.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,20,,0.024,Percent of Total Billed Charges,20% of Total Billed Charges,0.03,20,,0.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,20,,0.024,Percent of Total Billed Charges,20% of Total Billed Charges,0.03,20,,0.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,65,,0.072,Percent of Total Billed Charges,65% of Total Billed Charges,0.09,65,,0.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,53.67,
NF-Coenzyme Q-10 Oral Tablet 100MG,3061023,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
"NF-Epogen Injection 10,000U/ML",3061024,CDM,250,RC,,,Outpatient,,,370.8,185.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.16,20,,59.328,Percent of Total Billed Charges,20% of Total Billed Charges,74.16,20,,59.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.16,20,,59.328,Percent of Total Billed Charges,20% of Total Billed Charges,74.16,20,,59.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.02,65,,192.816,Percent of Total Billed Charges,65% of Total Billed Charges,241.02,65,,192.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,241.02,
NF-Vicks VapoRub Ointment 4.7%-1.2%-2.6%,3061026,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Citalopram Oral Tablet 10MG,3061028,CDM,250,RC,,,Outpatient,,,7.21,3.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,53.67,
NF-Lactulose Oral Solution 10GM/15ML,3061029,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Zinc Sulfate Oral Tablet 50MG,3061031,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Alendronate Sodium Oral Tablet 70MG,3061032,CDM,250,RC,,,Outpatient,,,62.83,31.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,53.67,
NF-Myrbetriq Oral Tablet 50MG,3061034,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"NF-Vitamin D2 Liquid-Filled Cap 50,000IU",3061036,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
DICLOFENAC TOPICAL GEL [1%]- **NF**,3061037,CDM,250,RC,,,Outpatient,,,15.82,7.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.16,20,,2.528,Percent of Total Billed Charges,20% of Total Billed Charges,3.16,20,,2.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.16,20,,2.528,Percent of Total Billed Charges,20% of Total Billed Charges,3.16,20,,2.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.28,65,,8.224,Percent of Total Billed Charges,65% of Total Billed Charges,10.28,65,,8.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.16,53.67,
NF-Azelastine HCl Nasal Spray 137MCG/1IN,3061038,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
NF-Voltaren Gel Topical Gel 1%,3061040,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Uloric Oral Tablet 40MG,3061041,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-APAP/Codeine Soln 120MG-12MG/5ML,3061042,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Gabapentin Oral Solution 250MG/5ML,3061043,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Levsin Oral Tablet 0.125MG,3061044,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-metFORMIN HCl Oral Soln 500MG/5ML,3061045,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Reglan Oral Tablet 5MG,3061046,CDM,250,RC,,,Outpatient,,,12.36,6.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,53.67,
DIABETISOURCE AC LIQ [1.2 KCAL/ML]- NF,3061047,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE FEEDING H2O(WATER)- NF,3061048,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Ibuprofen Tablet 200MG,3061049,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Entresto Oral Tablet 97MG-103MG,3061050,CDM,250,RC,,,Outpatient,,,41.2,20.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,53.67,
NF-Vicks Sinex 12 Hour Nasal Spray 0.05%,3061052,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THERATEARS DRY EYE THERAPY- NF,3061053,CDM,250,RC,,,Outpatient,,,6.18,3.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,53.67,
NF-PreserVision Areds 2 Oral Liq Cap,3061055,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Memantine HCl Oral Capsule ER 14MG,3061058,CDM,250,RC,,,Outpatient,,,46.35,23.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,53.67,
JEVITY 1.5 kCal (BOLUS),3061060,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ANORO ELLIPTA INH [62.5MCG/25MCG]-(NF),3061061,CDM,350,RC,,,Outpatient,,,28.84,14.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.75,65,,15,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,65,,15,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,407,
NF-B-12 Oral Tablet 1000MCG,3061062,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Coenzyme Q-10 Liquid Capsule 200MG,3061063,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Lisinopril Tablet 2.5mg,3061064,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Vitamin D-3 Oral Liquid Capsule 2000I,3061065,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Lisinopril Tablet 2.5mg,3061066,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Nortriptyline Oral Capsule 50MG,3061067,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
NF-Tradjenta Oral Tablet 5MG,3061068,CDM,250,RC,,,Outpatient,,,64.89,32.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,53.67,
PROMETHAZINE/NS IVPB: 12.5MG/50ML,3061069,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INF-PHYTONADIONE/NS IVPB: 10 MG/50ML,3061071,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Loteprednol Etabonate Ophth Gel 0.5%,3061074,CDM,250,RC,,,Outpatient,,,134.93,67.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.7,65,,70.16,Percent of Total Billed Charges,65% of Total Billed Charges,87.7,65,,70.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.99,87.7,
NF-Anoro Ellipta Inhalation Powder,3061075,CDM,250,RC,,,Outpatient,,,28.84,14.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.75,65,,15,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,65,,15,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,53.67,
NF-Daliresp Oral Tablet 500MCG,3061076,CDM,250,RC,,,Outpatient,,,30.9,15.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,53.67,
FARXIGA (DAPAGLIFLOZIN) TAB [10MG]- (NF),3061077,CDM,250,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
NF-Farxiga Oral Tablet 10MG,3061078,CDM,250,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3061080,CDM,250,RC,,,Outpatient,,,1642.85,821.43,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.57,20,,262.856,Percent of Total Billed Charges,20% of Total Billed Charges,328.57,20,,262.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.57,20,,262.856,Percent of Total Billed Charges,20% of Total Billed Charges,328.57,20,,262.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.85,65,,854.28,Percent of Total Billed Charges,65% of Total Billed Charges,1067.85,65,,854.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1067.85,
NF-Depakote Sprinkles Capsule 125MG,3061081,CDM,250,RC,,,Outpatient,,,6.18,3.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,53.67,
NF-traMADol HCl Oral Tablet 50MG,3061082,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-Gabapentin Oral Capsule 100MG,3061083,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-glipiZIDE Oral Tablet 5MG,3061084,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Bisacodyl Enteric Coated Tablet 5MG,3061086,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Bisacodyl Rectal Suppository 10MG,3061087,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Claritin 24Hour Oral Tablet 10MG,3061089,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Furosemide Oral Tablet 20MG,3061090,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Haloperidol Tablet 0.5MG,3061091,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Hyoscyamine  Tab  0.125MG,3061092,CDM,250,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
"NF-Imodium A-D Oral Cap, Liquid Filled 2",3061093,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-LORazepam Oral Tablet 0.5MG,3061094,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Milk Of Magnesia Liquid 400MG/5ML,3061095,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Morphine Sulfate Oral Solution 20MG/1,3061096,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-Nitroglycerin Sublingual Tab 0.3MG,3061097,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Ondansetron HCl Oral Tablet 4MG,3061099,CDM,250,RC,,,Outpatient,,,76.22,38.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,53.67,
NF-Senokot S Oral Tablet 50MG-8.6MG,3061100,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Tessalon Perles Capsule 100MG,3061102,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
NF-Tylenol Oral Tablet 325MG,3061103,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Zoloft Oral Tablet 50MG,3061104,CDM,250,RC,,,Outpatient,,,19.57,9.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.72,65,,10.176,Percent of Total Billed Charges,65% of Total Billed Charges,12.72,65,,10.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,53.67,
NF-Carvedilol Oral Tablet 3.125MG,3061106,CDM,250,RC,,,Outpatient,,,6.18,3.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,53.67,
NF-Budesonide-Formoterol Fum 160/4.5,3061107,CDM,250,RC,,,Outpatient,,,121.54,60.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,79,
NF-Imbruvica Oral Tablet 420MG,3061108,CDM,250,RC,,,Outpatient,,,2103.26,1051.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.65,20,,336.52,Percent of Total Billed Charges,20% of Total Billed Charges,420.65,20,,336.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.65,20,,336.52,Percent of Total Billed Charges,20% of Total Billed Charges,420.65,20,,336.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1367.12,65,,1093.696,Percent of Total Billed Charges,65% of Total Billed Charges,1367.12,65,,1093.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1367.12,
MURO-128 OPHTH OINTMENT [5%]- (NF),3061111,CDM,250,RC,,,Outpatient,,,76.22,38.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,53.67,
NF-Muro-128 Ophth Solution 5%,3061112,CDM,250,RC,,,Outpatient,,,20.6,10.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,53.67,
NF-ARIPiprazole AvPak Tablet 2MG,3061113,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ALENDRONATE SOD TAB [70 MG]- (NF),3061114,CDM,250,RC,,,Outpatient,,,5.92,2.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,1.18,20,,0.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.85,65,,3.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,53.67,
NF-Colesevelam HCl Oral Tablet 625MG,3061115,CDM,250,RC,,,Outpatient,,,11.33,5.67,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,2.27,20,,1.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.36,65,,5.888,Percent of Total Billed Charges,65% of Total Billed Charges,7.36,65,,5.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,53.67,
NF-Milk Of Magnesia Liquid 400MG/5ML,3061117,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Nitroglycerin Sublingual Tablet 0.3MG,3061118,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Ondansetron Hydrochloride Oral Tab 4M,3061119,CDM,250,RC,,,Outpatient,,,76.22,38.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,53.67,
ALENDRONATE TAB [35MG] -(NF),3061120,CDM,250,RC,,,Outpatient,,,62.83,31.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,53.67,
NF-Amantadine HCl Oral Capsule 100MG,3061121,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Rytary ExtendedRelease Cap 61.25MG-24,3061122,CDM,250,RC,,,Outpatient,,,17.51,8.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.38,65,,9.104,Percent of Total Billed Charges,65% of Total Billed Charges,11.38,65,,9.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,53.67,
NF-Rivastigmine TD Patch ER 9.5MG/24HR,3061123,CDM,250,RC,,,Outpatient,,,51.5,25.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,53.67,
NF-Propranolol ER Oral Cap ER 80MG,3061125,CDM,250,RC,,,Outpatient,,,14.42,7.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,53.67,
NF-Raloxifene HCl Oral Tablet 60MG,3061126,CDM,250,RC,,,Outpatient,,,21.63,10.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.06,65,,11.248,Percent of Total Billed Charges,65% of Total Billed Charges,14.06,65,,11.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,53.67,
NF-Mirtazapine Oral Tablet 7.5MG,3061127,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-valACYclovir HCl Oral Tablet 500MG,3061128,CDM,250,RC,,,Outpatient,,,21.63,10.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.06,65,,11.248,Percent of Total Billed Charges,65% of Total Billed Charges,14.06,65,,11.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,53.67,
NF-Fosamax Tablet 70MG,3061129,CDM,250,RC,,,Outpatient,,,130.81,65.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.03,65,,68.024,Percent of Total Billed Charges,65% of Total Billed Charges,85.03,65,,68.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,85.03,
NF-Bethanechol Chloride Oral Tablet 25MG,3061130,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
NF-Slow Magnesium Chloride Calcium Tab E,3061131,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Omega-3 Oral Liquid-Filled Capsule,3061132,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BETHaneCHOL TAB [50 MG]- (NF),3061133,CDM,250,RC,,,Outpatient,,,10.3,5.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,53.67,
NF-Mirtazapine Oral Tablet 7.5MG,3061134,CDM,250,RC,,,Outpatient,,,7.21,3.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,53.67,
NF-Entresto Oral Tablet 49MG-51MG,3061138,CDM,250,RC,,,Outpatient,,,27.81,13.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,53.67,
NF-Bethanechol Chloride Oral Tablet 50MG,3061140,CDM,250,RC,,,Outpatient,,,12.36,6.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,53.67,
NF-hydrALAZINE HCl Oral Tab 100MG,3061141,CDM,250,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
NF-Labetalol HCl Tablet 200MG,3061142,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-NIFEdipine AvPak Tab ER 60MG,3061143,CDM,250,RC,,,Outpatient,,,6.18,3.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,53.67,
CENTRUM SILVER TAB -(NF),3061144,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OMEGA-3 / VIT D3 [600 MG-2000 I.U]- (NF),3061145,CDM,637,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Methocarbamol  Tab  750MG,3061146,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VANCOMYCIN PREMIXED[1250 MG/250 ML] IVPB,3061147,CDM,258,RC,,,Outpatient,,,70.45,35.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.09,20,,11.272,Percent of Total Billed Charges,20% of Total Billed Charges,14.09,20,,11.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.09,20,,11.272,Percent of Total Billed Charges,20% of Total Billed Charges,14.09,20,,11.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.79,65,,36.632,Percent of Total Billed Charges,65% of Total Billed Charges,45.79,65,,36.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.09,53.67,
VANCOMYCIN PREMIXED [1500 MG/300ML] IVPB,3061148,CDM,258,RC,,,Outpatient,,,84.54,42.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,20,,13.528,Percent of Total Billed Charges,20% of Total Billed Charges,16.91,20,,13.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,20,,13.528,Percent of Total Billed Charges,20% of Total Billed Charges,16.91,20,,13.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,65,,43.96,Percent of Total Billed Charges,65% of Total Billed Charges,54.95,65,,43.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,54.95,
VANCOMYCIN PREMIXED[1750 MG/350 ML] IVPB,3061149,CDM,258,RC,,,Outpatient,,,98.63,49.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.73,20,,15.784,Percent of Total Billed Charges,20% of Total Billed Charges,19.73,20,,15.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.73,20,,15.784,Percent of Total Billed Charges,20% of Total Billed Charges,19.73,20,,15.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.11,65,,51.288,Percent of Total Billed Charges,65% of Total Billed Charges,64.11,65,,51.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.73,64.11,
VANCOMYCIN PREMIXED[2000 MG/400 ML] IVPB,3061150,CDM,258,RC,,,Outpatient,,,112.71,56.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.54,20,,18.032,Percent of Total Billed Charges,20% of Total Billed Charges,22.54,20,,18.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.54,20,,18.032,Percent of Total Billed Charges,20% of Total Billed Charges,22.54,20,,18.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.26,65,,58.608,Percent of Total Billed Charges,65% of Total Billed Charges,73.26,65,,58.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.54,73.26,
FLECAINIDE ACETATE TAB [50MG]- (NF),3061153,CDM,250,RC,,,Outpatient,,,6.18,3.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,53.67,
NF-Niacin Flush Free Cap 100MG-400MG,3061156,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Indapamide Oral Tablet 2.5MG,3061157,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Synthroid Tablet 150MCG,3061158,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
NF-Valsartan Oral Tablet 320MG,3061159,CDM,250,RC,,,Outpatient,,,19.57,9.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,3.91,20,,3.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.72,65,,10.176,Percent of Total Billed Charges,65% of Total Billed Charges,12.72,65,,10.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,53.67,
NF-Calcium Magnesium Zinc w/Vitamin D Ta,3061162,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Morphine Sulfate Oral Solution 20MG/1,3061163,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-Lasix Tablet 80MG,3061166,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Senna Plus Oral Tablet 50MG-8.6MG,3061167,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-GNP Milk Of Magnesia Susp 1200MG/15ML,3061168,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RYBELSUS (SEMAGLUTIDE) TAB [14MG]- (NF),3061170,CDM,250,RC,,,Outpatient,,,115.36,57.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,74.98,
NF-Combigan Ophth Soln 0.2%-0.5%,3061172,CDM,250,RC,,,Outpatient,,,150.38,75.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,97.75,
NF-Procardia XL Tablet 90MG,3061173,CDM,250,RC,,,Outpatient,,,48.41,24.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.68,20,,7.744,Percent of Total Billed Charges,20% of Total Billed Charges,9.68,20,,7.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.68,20,,7.744,Percent of Total Billed Charges,20% of Total Billed Charges,9.68,20,,7.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.47,65,,25.176,Percent of Total Billed Charges,65% of Total Billed Charges,31.47,65,,25.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.68,53.67,
LACOSAMIDE (VIMPAT) TAB [150MG]- (NF),3061174,CDM,250,RC,,,Outpatient,,,54.59,27.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.48,65,,28.384,Percent of Total Billed Charges,65% of Total Billed Charges,35.48,65,,28.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,53.67,
NF-Xcopri Titration Pack 12.5MG/25MG,3061177,CDM,250,RC,,,Outpatient,,,13.39,6.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,53.67,
NF-Xcopri Titration Pack 12.5MG/25MG,3061178,CDM,250,RC,,,Outpatient,,,13.39,6.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,53.67,
NF-Terazosin HCl Capsule 5MG,3061179,CDM,250,RC,,,Outpatient,,,4.12,2.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,53.67,
NF-Ozempic SubQ Soln 2MG/3ML,3061180,CDM,250,RC,,,Outpatient,,,1155.66,577.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.13,20,,184.904,Percent of Total Billed Charges,20% of Total Billed Charges,231.13,20,,184.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.13,20,,184.904,Percent of Total Billed Charges,20% of Total Billed Charges,231.13,20,,184.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,751.18,65,,600.944,Percent of Total Billed Charges,65% of Total Billed Charges,751.18,65,,600.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,751.18,
NF-Ezetimibe Oral Tablet 10MG,3061182,CDM,250,RC,,,Outpatient,,,30.9,15.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,53.67,
Morphine Sulfate Oral Solution 20MG/1 NF,3061184,CDM,350,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,407,
MORPHINE SULFATE ORAL SOL[20MG/ML]-(NF),3061186,CDM,637,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-busPIRone HCl Tablet 5MG,3061187,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-Fiber Health Tablet,3061189,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Valsartan/HCTZ Oral Tablet 320MG-12.5,3061190,CDM,250,RC,,,Outpatient,,,16.48,8.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,53.67,
NF-Estradiol Vaginal Cream 0.1MG/1GM,3061191,CDM,250,RC,,,Outpatient,,,21.63,10.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,4.33,20,,3.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.06,65,,11.248,Percent of Total Billed Charges,65% of Total Billed Charges,14.06,65,,11.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,53.67,
NF-Exelon TD Patch ER 9.5MG/24HR,3061192,CDM,250,RC,,,Outpatient,,,84.46,42.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,54.9,
NF-Pataday 24HR Ophthalmic Solution 0.7%,3061193,CDM,250,RC,,,Outpatient,,,17.51,8.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.38,65,,9.104,Percent of Total Billed Charges,65% of Total Billed Charges,11.38,65,,9.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,53.67,
NF-Trulicity SubQ Soln 3MG/0.5ML,3061194,CDM,250,RC,,,Outpatient,,,1642.85,821.43,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.57,20,,262.856,Percent of Total Billed Charges,20% of Total Billed Charges,328.57,20,,262.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.57,20,,262.856,Percent of Total Billed Charges,20% of Total Billed Charges,328.57,20,,262.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.85,65,,854.28,Percent of Total Billed Charges,65% of Total Billed Charges,1067.85,65,,854.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1067.85,
NF-Vitamin D3 Oral Capsule 50000IU,3061195,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Ozempic SubQ Soln 2MG/3ML,3061197,CDM,250,RC,,,Outpatient,,,1155.66,577.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.13,20,,184.904,Percent of Total Billed Charges,20% of Total Billed Charges,231.13,20,,184.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.13,20,,184.904,Percent of Total Billed Charges,20% of Total Billed Charges,231.13,20,,184.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,751.18,65,,600.944,Percent of Total Billed Charges,65% of Total Billed Charges,751.18,65,,600.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,751.18,
NF-Abiraterone Acetate Oral Tablet 250MG,3061198,CDM,250,RC,,,Outpatient,,,299.73,149.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.82,65,,155.856,Percent of Total Billed Charges,65% of Total Billed Charges,194.82,65,,155.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,194.82,
NF-amLODIPine Besylate Oral Tablet 10MG,3061199,CDM,250,RC,,,Outpatient,,,7.21,3.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,53.67,
NF-Atorvastatin Calcium Oral Tab 20MG,3061200,CDM,250,RC,,,Outpatient,,,17.51,8.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,3.5,20,,2.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.38,65,,9.104,Percent of Total Billed Charges,65% of Total Billed Charges,11.38,65,,9.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,53.67,
NF-Lisinopril Tablet 20mg,3061201,CDM,250,RC,,,Outpatient,,,3.09,1.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
NF-predniSONE Tablet 10MG,3061202,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Olopatadine HCl Ophthalmic Solution 0,3061203,CDM,250,RC,,,Outpatient,,,164.8,82.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,107.12,
NF-predniSONE Oral Tablet 5MG,3061204,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-buPROPion Hydrochloride Oral Tab 100M,3061205,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Juven Oral Powder for Solution,3061206,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vitamin B12 Tablet 2500mcg,3061207,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Iron Oral Tablet 27MG,3061208,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vitamin B12 Tablet 1000mcg,3061209,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vitamin D Oral Tablet 5000IU,3061210,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
CALCITONIN/SALM NAS SPR [200 IU/SPRY]-NF,3061211,CDM,250,RC,,,Outpatient,,,98.88,49.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,64.27,
Fem pH Vaginal Gel/Jelly NF,3061214,CDM,250,RC,,,Outpatient,,,7.21,3.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,53.67,
LOTEPREDNOL(LOTEMAX)OPHT SUSP[0.5%]-(NF),3061215,CDM,250,RC,,,Outpatient,,,158.62,79.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.1,65,,82.48,Percent of Total Billed Charges,65% of Total Billed Charges,103.1,65,,82.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.72,103.1,
NF-Oyster Shell Calcium/Vitamin D Tablet,3061216,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SOD Cl (MURO-128) OPHTH SOL [5%]-(NF),3061217,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
SPIRIVA INH/NEB CAP [18MCG] - (NF),3061218,CDM,250,RC,,,Outpatient,,,26.78,13.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,53.67,
NF-Theophylline Tablet 300MG,3061219,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
CENTRUM SILVER TAB [WOMEN 50+]-(NF),3061220,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CERAVE MOISTURIZING CREAM - (NF),3061221,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ATACAND(CANDESARTAN) TAB [8 MG]-(NF),3061222,CDM,250,RC,,,Outpatient,,,27.81,13.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,53.67,
THEOPHYLLINE TAB ER [600MG] -(NF),3061223,CDM,250,RC,,,Outpatient,,,5.15,2.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,1.03,20,,0.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,3.35,65,,2.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,53.67,
XIIDRA (LIFITEGRAST) OPHT SOL [5%]-(NF),3061225,CDM,250,RC,,,Outpatient,,,33.99,17.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,53.67,
OxyCONTIN Tablet Extended Release 20MNF,3061226,CDM,250,RC,,,Outpatient,,,12.36,6.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,53.67,
OxyCONTIN (OXYCODONE) ER TAB [20 MG]- NF,3061227,CDM,250,RC,,,Outpatient,,,12.36,6.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,53.67,
MYRBETRIQ(MIRABEGRON) TAB ER [25MG]-(NF),3061228,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Myrbetriq Oral Tablet ER 25MG,3061229,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Dorzolamide Hydrochloride and Timolol,3061230,CDM,250,RC,,,Outpatient,,,37.08,18.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,53.67,
NF-Theophylline Oral Tab ER 300MG,3061231,CDM,250,RC,,,Outpatient,,,12.36,6.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,53.67,
TRIMO-SAN VAG GEL/JELLY[0.025-0.01%](NF),3061232,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ESTRIOL/ALOE/VIT E [0.1/0.05%/25IU/G]NF,3061233,CDM,250,RC,,,Outpatient,,,1430.67,715.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.13,20,,228.904,Percent of Total Billed Charges,20% of Total Billed Charges,286.13,20,,228.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.13,20,,228.904,Percent of Total Billed Charges,20% of Total Billed Charges,286.13,20,,228.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,929.94,65,,743.952,Percent of Total Billed Charges,65% of Total Billed Charges,929.94,65,,743.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,929.94,
EFFIENT(PRASUGREL) TAB [10 MG]-(NF),3061234,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Atorvastatin Calcium Oral Tab 10MG,3061237,CDM,250,RC,,,Outpatient,,,12.36,6.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,53.67,
NF-Advanced Sleep Melatonin Tab ER 10MG,3061239,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CENTRUM SILVER TAB -(NF),3061240,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Eucerin Topical Cream,3061241,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"NF-Omega-3 Oral Capsule, Liq Cap 1000MG",3061242,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Pravastatin Sodium Oral Tablet 10MG,3061243,CDM,250,RC,,,Outpatient,,,9.27,4.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.85,20,,1.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,65,,4.824,Percent of Total Billed Charges,65% of Total Billed Charges,6.03,65,,4.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,53.67,
NF-Multivitamin Tablet,3061244,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Thermotabs Oral Tablet 287MG-180MG-15,3061246,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENTRESTO TAB [24MG-26MG]- (NF),3061247,CDM,250,RC,,,Outpatient,,,27.81,13.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,53.67,
NF-Escitalopram Oral Tablet 5MG,3061248,CDM,250,RC,,,Outpatient,,,12.36,6.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,53.67,
OYSTERSHELL Ca w/VITD3 [500MG-5MCG]-(NF),3061250,CDM,637,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OYSTERSHELL Ca w/Vit D3[500MG-10MCG]-NF,3061251,CDM,637,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ANASTROZOLE (ARIMIDEX) TAB [1 MG]-(NF),3061252,CDM,250,RC,,,Outpatient,,,41.2,20.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,53.67,
MAGNESIUM TAB [250 MG]-(NF),3061253,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Myrbetriq Oral Tablet 50MG,3061254,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERQUVO(VERICIGUAT) TAB [10 MG]-(NF),3061255,CDM,250,RC,,,Outpatient,,,79.31,39.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.86,53.67,
NF-Milk Of Magnesia Oral Susp 2400MG/30M,3061258,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OMEPRAZOLE DR(PriLOSEC) CAP [40 MG]-(NF),3061260,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Hyoscyamine Sulfate Elixir 0.125MG/5M,3061264,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Morphine Sulfate Oral Solution 20MG/1,3061265,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-Travoprost Ophthalmic Solution 0.004%,3061266,CDM,250,RC,,,Outpatient,,,245.14,122.57,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.03,20,,39.224,Percent of Total Billed Charges,20% of Total Billed Charges,49.03,20,,39.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.03,20,,39.224,Percent of Total Billed Charges,20% of Total Billed Charges,49.03,20,,39.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.34,65,,127.472,Percent of Total Billed Charges,65% of Total Billed Charges,159.34,65,,127.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.03,159.34,
NF-Tylenol Arthritis Oral Tablet 650MG,3061268,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Desitin Original Topical Ointment 40%,3061269,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Haloperidol Tablet 0.5MG,3061270,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Acetaminophen Capsule 500MG,3061271,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Benadryl Itch Stopping Gel,3061272,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Calmoseptine Ointment,3061273,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Ondansetron Disintegrating Tablet 8MG,3061274,CDM,250,RC,,,Outpatient,,,115.36,57.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,74.98,
NF-Omeprazole Delayed-Release Capsule 40,3061275,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Zofran Tablet 8MG,3061276,CDM,250,RC,,,Outpatient,,,143.17,71.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,93.06,
NF-Genvoya Oral Tablet,3061277,CDM,250,RC,,,Outpatient,,,468.65,234.33,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.73,20,,74.984,Percent of Total Billed Charges,20% of Total Billed Charges,93.73,20,,74.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.73,20,,74.984,Percent of Total Billed Charges,20% of Total Billed Charges,93.73,20,,74.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.62,65,,243.696,Percent of Total Billed Charges,65% of Total Billed Charges,304.62,65,,243.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,304.62,
NF-Magnesium Oxide Tablet 400MG,3061278,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Cellcept Tablet 500MG,3061280,CDM,250,RC,,,Outpatient,,,65.92,32.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.85,65,,34.28,Percent of Total Billed Charges,65% of Total Billed Charges,42.85,65,,34.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,53.67,
NF-Cellcept Tablet 500MG,3061281,CDM,250,RC,,,Outpatient,,,65.92,32.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,13.18,20,,10.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.85,65,,34.28,Percent of Total Billed Charges,65% of Total Billed Charges,42.85,65,,34.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,53.67,
NF-valsartan Oral Tablet 80MG,3061282,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Verapamil HCl Tablet 180MG,3061284,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Brovana Inhalation Solution 15MCG/2ML,3061287,CDM,250,RC,,,Outpatient,,,33.99,17.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,53.67,
NF-Vitamin B Complex Capsule,3061290,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Senexon-S Oral Tablet 50MG-8.6MG,3061291,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Flovent HFA Inh Oral/Neb 0.11MG/1Act,3061292,CDM,250,RC,,,Outpatient,,,84.46,42.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,54.9,
NF-Flovent HFA Inh Oral/Neb 0.11MG/1Act,3061295,CDM,250,RC,,,Outpatient,,,84.46,42.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,54.9,
NF-Amantadine HCl Oral Capsule 100MG,3061296,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Doxepin Oral Capsule 50MG,3061299,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
NF-Doxepin Oral Capsule 50MG,3061300,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
NF-Abilify Oral Tablet 5MG,3061301,CDM,250,RC,,,Outpatient,,,72.1,36.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,53.67,
NF-Austedo Oral Tablet 6MG,3061302,CDM,250,RC,,,Outpatient,,,291.49,145.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.3,20,,46.64,Percent of Total Billed Charges,20% of Total Billed Charges,58.3,20,,46.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.3,20,,46.64,Percent of Total Billed Charges,20% of Total Billed Charges,58.3,20,,46.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.47,65,,151.576,Percent of Total Billed Charges,65% of Total Billed Charges,189.47,65,,151.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,189.47,
NF-fluPHENAZine HCl Tablet 10MG,3061303,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Trihexyphenidyl HCl Tablet 5MG,3061304,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Rosuvastatin Oral Tablet 40MG,3061305,CDM,250,RC,,,Outpatient,,,26.78,13.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,53.67,
NF-Leflunomide Oral Tablet 20MG,3061310,CDM,250,RC,,,Outpatient,,,50.47,25.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,53.67,
NF-Vimpat Oral Tablet 50MG,3061311,CDM,250,RC,,,Outpatient,,,41.2,20.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,53.67,
NF-PreserVision Areds 2 Oral Liq Cap,3061312,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Rosuvastatin Oral Tablet 40MG,3061313,CDM,250,RC,,,Outpatient,,,26.78,13.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,53.67,
NF-Probenecid Tablet 500MG,3061314,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
NF-Phillips' Milk of Magnesia 1200MG/15M,3061315,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Rinvoq Oral Tab ER 15MG,3061316,CDM,250,RC,,,Outpatient,,,757.05,378.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.41,20,,121.128,Percent of Total Billed Charges,20% of Total Billed Charges,151.41,20,,121.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.41,20,,121.128,Percent of Total Billed Charges,20% of Total Billed Charges,151.41,20,,121.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.08,65,,393.664,Percent of Total Billed Charges,65% of Total Billed Charges,492.08,65,,393.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,492.08,
NF-Bethanechol Chloride Oral Tablet 25MG,3061317,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
NF-ARIPiprazole Oral Tablet 10MG,3061318,CDM,250,RC,,,Outpatient,,,98.88,49.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,64.27,
NF-PARoxetine HCl Tablet 30MG,3061319,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
VITD3(CHOLECALCIFEROL)TAB [2000 I.U.]-NF,3061323,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-PARoxetine HCl Tablet 30MG,3061325,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3061328,CDM,250,RC,,,Outpatient,,,1725.25,862.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.05,20,,276.04,Percent of Total Billed Charges,20% of Total Billed Charges,345.05,20,,276.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.05,20,,276.04,Percent of Total Billed Charges,20% of Total Billed Charges,345.05,20,,276.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1121.41,65,,897.128,Percent of Total Billed Charges,65% of Total Billed Charges,1121.41,65,,897.128,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1121.41,
NF-Mycophenolate Mofetil Oral Tablet 500,3061329,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Mycophenolate Mofetil Oral Tablet 500,3061330,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Mycophenolate Mofetil Tablet 500MG,3061331,CDM,250,RC,,,Outpatient,,,23.69,11.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,53.67,
NF-NovoLIN 70/30 SubQ Susp 70U-30U/1ML,3061332,CDM,250,RC,,,Outpatient,,,50.47,25.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,53.67,
NF-NovoLIN 70/30 SubQ Susp 70U-30U/1ML,3061333,CDM,250,RC,,,Outpatient,,,50.47,25.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,53.67,
NF-Refresh Ophth Solution,3061334,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Amantadine HCl Tablet 100MG,3061338,CDM,250,RC,,,Outpatient,,,6.18,3.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,1.24,20,,0.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,4.02,65,,3.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,53.67,
IRON SUCROSE/NS IVPB: [500 MG/250 ML],3061343,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-ARIPiprazole Oral Tablet 10MG,3061344,CDM,250,RC,,,Outpatient,,,98.88,49.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,64.27,
NF-Excedrin Tension Headache 500MG-65MG,3061345,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Menthol Topical Gel 2%,3061346,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-L-Methylfolate Oral Tablet 15MG,3061347,CDM,250,RC,,,Outpatient,,,8.24,4.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.65,20,,1.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,5.36,65,,4.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,53.67,
NF-Carisoprodol Oral Tablet 350MG,3061348,CDM,250,RC,,,Outpatient,,,1.03,0.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,0.21,20,,0.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,0.67,65,,0.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,53.67,
NF-Slow Fe Oral Tablet 45MG,3061349,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vitamin D Oral Liq Cap 1.25MG,3061350,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
NF-Breztri Aerosphere Inh Aer Liq,3061351,CDM,250,RC,,,Outpatient,,,210,105.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,65,,109.2,Percent of Total Billed Charges,65% of Total Billed Charges,136.5,65,,109.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,136.5,
NF-Nexlizet Oral Tab 180MG-10MG,3061353,CDM,250,RC,,,Outpatient,,,47,23.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,53.67,
NF-Culturelle Oral Capsule 10 Billion OR,3061354,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Arava Tablet 20MG,3061355,CDM,250,RC,,,Outpatient,,,179,89.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.8,20,,28.64,Percent of Total Billed Charges,20% of Total Billed Charges,35.8,20,,28.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.8,20,,28.64,Percent of Total Billed Charges,20% of Total Billed Charges,35.8,20,,28.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.35,65,,93.08,Percent of Total Billed Charges,65% of Total Billed Charges,116.35,65,,93.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.8,116.35,
NF-Vitamin D Oral Capsule 50000IU,3061364,CDM,250,RC,,,Outpatient,,,4,2.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,53.67,
NF-Rosuvastatin Oral Tablet 20MG,3061365,CDM,250,RC,,,Outpatient,,,26,13.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,53.67,
NF-Trintellix Oral Tablet 10MG,3061366,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Paxlovid Oral Tab 150MG;100MG,3061367,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Bethanechol Chloride Oral Tablet 10MG,3061368,CDM,250,RC,,,Outpatient,,,6,3.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,53.67,
NF-Morphine Sulfate Tablet ER 200MG,3061370,CDM,250,RC,,,Outpatient,,,55,27.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,53.67,
NF-oxyCODONE Hydrochloride Oral Tablet 2,3061371,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-oxyCODONE HCl Oral Tablet  ER 20MG,3061372,CDM,250,RC,,,Outpatient,,,17,8.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,53.67,
NF-Pentoxifylline Tablet 400MG,3061377,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Gemtesa Oral Tablet 75MG,3061378,CDM,250,RC,,,Outpatient,,,56,28.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,20,,8.96,Percent of Total Billed Charges,20% of Total Billed Charges,11.2,20,,8.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,20,,8.96,Percent of Total Billed Charges,20% of Total Billed Charges,11.2,20,,8.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.4,65,,29.12,Percent of Total Billed Charges,65% of Total Billed Charges,36.4,65,,29.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,53.67,
NF-Sotalol HCl Tablet 120MG,3061379,CDM,250,RC,,,Outpatient,,,10,5.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,53.67,
NF-Vitamin D3 Oral Cap 1250MCG,3061380,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Crestor Oral Tablet 5MG,3061382,CDM,250,RC,,,Outpatient,,,33,16.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,53.67,
NF-Levemir Subcutaneous Solution 100U/1M,3061383,CDM,250,RC,,,Outpatient,,,110,55.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.5,65,,57.2,Percent of Total Billed Charges,65% of Total Billed Charges,71.5,65,,57.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,71.5,
NF-Hyzaar Oral Tablet 100MG-25MG,3061384,CDM,250,RC,,,Outpatient,,,23,11.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,65,,11.96,Percent of Total Billed Charges,65% of Total Billed Charges,14.95,65,,11.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,53.67,
NF-Nesina Oral Tablet 25MG,3061386,CDM,250,RC,,,Outpatient,,,49,24.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,53.67,
NF-Simvastatin Oral Tablet 40MG,3061387,CDM,250,RC,,,Outpatient,,,14,7.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,53.67,
NF-Docusate Sodium Capsule 100MG,3061388,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Premarin Oral Tablet 0.45MG,3061389,CDM,250,RC,,,Outpatient,,,24,12.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,53.67,
GENERAL-SPLINT ORDER,3061390,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Creon Oral Cap DR 24000U-76000U-12000,3061392,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Creon Oral Cap DR 24000U-76000U-12000,3061393,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3061397,CDM,250,RC,,,Outpatient,,,1675,837.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335,20,,268,Percent of Total Billed Charges,20% of Total Billed Charges,335,20,,268,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335,20,,268,Percent of Total Billed Charges,20% of Total Billed Charges,335,20,,268,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1088.75,65,,871,Percent of Total Billed Charges,65% of Total Billed Charges,1088.75,65,,871,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1088.75,
NF-Revlimid Oral Capsule 10MG,3061398,CDM,250,RC,,,Outpatient,,,2999,1499.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,599.8,20,,479.84,Percent of Total Billed Charges,20% of Total Billed Charges,599.8,20,,479.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,599.8,20,,479.84,Percent of Total Billed Charges,20% of Total Billed Charges,599.8,20,,479.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.35,65,,1559.48,Percent of Total Billed Charges,65% of Total Billed Charges,1949.35,65,,1559.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1949.35,
NF-Lisinopril-HCTZ  Oral Tablet 20MG-12.,3061404,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Ozempic 1MG Doses SubQ Soln 4MG/3ML,3061406,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Sildenafil Oral Tablet 20MG,3061407,CDM,250,RC,,,Outpatient,,,63,31.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,53.67,
NF-Metaxalone Oral Tablet 800MG,3061408,CDM,250,RC,,,Outpatient,,,15,7.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,53.67,
NF-Opsumit Oral Tablet 10MG,3061409,CDM,250,RC,,,Outpatient,,,1449,724.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.8,20,,231.84,Percent of Total Billed Charges,20% of Total Billed Charges,289.8,20,,231.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.8,20,,231.84,Percent of Total Billed Charges,20% of Total Billed Charges,289.8,20,,231.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,941.85,65,,753.48,Percent of Total Billed Charges,65% of Total Billed Charges,941.85,65,,753.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,941.85,
LIDOCAINE / TOPICAL PF SYR JELLY 2%,3061410,CDM,250,RC,,,Outpatient,,,7.89,3.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,20,,1.264,Percent of Total Billed Charges,20% of Total Billed Charges,1.58,20,,1.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,20,,1.264,Percent of Total Billed Charges,20% of Total Billed Charges,1.58,20,,1.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.13,65,,4.104,Percent of Total Billed Charges,65% of Total Billed Charges,5.13,65,,4.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,53.67,
NF-Cosopt Ophth Solution 2%/0.5%,3061411,CDM,250,RC,,,Outpatient,,,80,40.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52,65,,41.6,Percent of Total Billed Charges,65% of Total Billed Charges,52,65,,41.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,53.67,
NF-Omeprazole Oral Tablet DR 20MG,3061412,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Zofran Tablet 8MG,3061413,CDM,250,RC,,,Outpatient,,,139,69.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,20,,22.24,Percent of Total Billed Charges,20% of Total Billed Charges,27.8,20,,22.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,20,,22.24,Percent of Total Billed Charges,20% of Total Billed Charges,27.8,20,,22.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.35,65,,72.28,Percent of Total Billed Charges,65% of Total Billed Charges,90.35,65,,72.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,90.35,
NF-Zofran Tablet 8MG,3061414,CDM,250,RC,,,Outpatient,,,139,69.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,20,,22.24,Percent of Total Billed Charges,20% of Total Billed Charges,27.8,20,,22.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,20,,22.24,Percent of Total Billed Charges,20% of Total Billed Charges,27.8,20,,22.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.35,65,,72.28,Percent of Total Billed Charges,65% of Total Billed Charges,90.35,65,,72.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,90.35,
TRIAMCINOLONE INJ SUSP[40 MG/ ML],3061416,CDM,250,RC,J3490,HCPCS,Outpatient,,,11.66,5.83,,7.58,65,,6.064,Percent of Total Billed Charges,65% of Total Billed Charges,7.93,68,,6.344,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,20,,1.864,Percent of Total Billed Charges,20% of Total Billed Charges,2.33,20,,1.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,20,,1.864,Percent of Total Billed Charges,20% of Total Billed Charges,2.33,20,,1.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.58,65,,6.064,Percent of Total Billed Charges,65% of Total Billed Charges,7.58,65,,6.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,53.67,
NF-Ibandronate Sodium Tab 150MG,3061417,CDM,250,RC,,,Outpatient,,,416,208.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.2,20,,66.56,Percent of Total Billed Charges,20% of Total Billed Charges,83.2,20,,66.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.2,20,,66.56,Percent of Total Billed Charges,20% of Total Billed Charges,83.2,20,,66.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.4,65,,216.32,Percent of Total Billed Charges,65% of Total Billed Charges,270.4,65,,216.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,270.4,
NF-Boniva Oral Tablet 150MG,3061418,CDM,250,RC,,,Outpatient,,,687,343.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.4,20,,109.92,Percent of Total Billed Charges,20% of Total Billed Charges,137.4,20,,109.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.4,20,,109.92,Percent of Total Billed Charges,20% of Total Billed Charges,137.4,20,,109.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.55,65,,357.24,Percent of Total Billed Charges,65% of Total Billed Charges,446.55,65,,357.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,446.55,
NF-Irbesartan Oral Tablet 150MG,3061421,CDM,250,RC,,,Outpatient,,,9,4.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,53.67,
NF-Amoxicillin Tablet 875MG,3061422,CDM,250,RC,,,Outpatient,,,2,1.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,53.67,
VAC- INFLUENZA INJ SYR [0.5 ML] *65YO&UP,3061423,CDM,250,RC,90694,HCPCS,Outpatient,,,121.24,60.62,,78.81,65,,63.048,Percent of Total Billed Charges,65% of Total Billed Charges,82.44,68,,65.952,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.25,20,,19.4,Percent of Total Billed Charges,20% of Total Billed Charges,24.25,20,,19.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.25,20,,19.4,Percent of Total Billed Charges,20% of Total Billed Charges,24.25,20,,19.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.81,65,,63.048,Percent of Total Billed Charges,65% of Total Billed Charges,78.81,65,,63.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.25,82.44,
NF-Black Elderberry Gummies Chew,3061424,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vitafusion MVI Oral Chew GUMMIES,3061425,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VAC- RABIES INJ [1 ML (2.5 IU)] SDV *IM*,3061427,CDM,258,RC,90675,HCPCS,Outpatient,,,793.48,396.74,,515.76,65,,412.608,Percent of Total Billed Charges,65% of Total Billed Charges,539.57,68,,431.656,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.7,20,,126.96,Percent of Total Billed Charges,20% of Total Billed Charges,158.7,20,,126.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.7,20,,126.96,Percent of Total Billed Charges,20% of Total Billed Charges,158.7,20,,126.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,515.76,65,,412.608,Percent of Total Billed Charges,65% of Total Billed Charges,515.76,65,,412.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,539.57,
NF-Memantine HCl Oral Capsule ER 28MG,3061428,CDM,250,RC,,,Outpatient,,,45,22.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.25,65,,23.4,Percent of Total Billed Charges,65% of Total Billed Charges,29.25,65,,23.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,53.67,
NF-Veltassa PowderforSuspension 8.4GM/1P,3061429,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Acetaminophen Oral Tab ER 650MG,3061433,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Naproxen Oral Tablet 220MG,3061434,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Pregabalin Oral Cap 225MG,3061443,CDM,250,RC,,,Outpatient,,,25,12.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,53.67,
NF-Prazosin HCl Capsule 1MG,3061446,CDM,250,RC,,,Outpatient,,,2,1.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,53.67,
NF-Estradiol Tablet 1MG,3061448,CDM,250,RC,,,Outpatient,,,2,1.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,53.67,
NF-Spiriva HandiHaler Inh/Neb Cap 18MCG,3061450,CDM,250,RC,,,Outpatient,,,61,30.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.2,20,,9.76,Percent of Total Billed Charges,20% of Total Billed Charges,12.2,20,,9.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.2,20,,9.76,Percent of Total Billed Charges,20% of Total Billed Charges,12.2,20,,9.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.65,65,,31.72,Percent of Total Billed Charges,65% of Total Billed Charges,39.65,65,,31.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.2,53.67,
DDR PRIME MVI TAB - (NF),3061453,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Ciclopirox Olamine Topical Cream 0.77,3061454,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
NF-Fluocinonide Solution 0.05%,3061455,CDM,250,RC,,,Outpatient,,,4,2.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,53.67,
NF-Breztri Aerosphere Inh Aer Liq,3061456,CDM,250,RC,,,Outpatient,,,210,105.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,65,,109.2,Percent of Total Billed Charges,65% of Total Billed Charges,136.5,65,,109.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,136.5,
NF-oxyCODONE-Acetaminophen Tab 7.5MG-325,3061457,CDM,250,RC,,,Outpatient,,,8,4.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
NF-busPIRone Oral Tablet 10MG,3061458,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Rivastigmine TD Patch ER 4.6MG/24HR,3061459,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-TraZODone HCl Oral Tablet 100MG,3061460,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Simethicone Chewable Tab 80MG,3061461,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Tolvaptan Oral Tablet 15MG,3061462,CDM,250,RC,,,Outpatient,,,1694,847.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.8,20,,271.04,Percent of Total Billed Charges,20% of Total Billed Charges,338.8,20,,271.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.8,20,,271.04,Percent of Total Billed Charges,20% of Total Billed Charges,338.8,20,,271.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1101.1,65,,880.88,Percent of Total Billed Charges,65% of Total Billed Charges,1101.1,65,,880.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1101.1,
NF-B12-Methyl Oral Capsule 1000MCG,3061463,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Ofev Oral Capsule 150MG,3061464,CDM,250,RC,,,Outpatient,,,749,374.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.8,20,,119.84,Percent of Total Billed Charges,20% of Total Billed Charges,149.8,20,,119.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.8,20,,119.84,Percent of Total Billed Charges,20% of Total Billed Charges,149.8,20,,119.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,65,,389.48,Percent of Total Billed Charges,65% of Total Billed Charges,486.85,65,,389.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,486.85,
NF-Opsumit Oral Tablet 10MG,3061465,CDM,250,RC,,,Outpatient,,,1449,724.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.8,20,,231.84,Percent of Total Billed Charges,20% of Total Billed Charges,289.8,20,,231.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.8,20,,231.84,Percent of Total Billed Charges,20% of Total Billed Charges,289.8,20,,231.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,941.85,65,,753.48,Percent of Total Billed Charges,65% of Total Billed Charges,941.85,65,,753.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,941.85,
NF-Sildenafil Oral Tablet 20MG,3061466,CDM,250,RC,,,Outpatient,,,63,31.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,53.67,
NF-Uptravi Oral Tablet 1600MCG,3061467,CDM,250,RC,,,Outpatient,,,1331,665.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.2,20,,212.96,Percent of Total Billed Charges,20% of Total Billed Charges,266.2,20,,212.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.2,20,,212.96,Percent of Total Billed Charges,20% of Total Billed Charges,266.2,20,,212.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,865.15,65,,692.12,Percent of Total Billed Charges,65% of Total Billed Charges,865.15,65,,692.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,865.15,
VAC- PREVNAR 20 INJ [0.5 ML] *IM*,3061468,CDM,636,RC,90677,HCPCS,Outpatient,,,537.94,268.97,,349.66,65,,279.728,Percent of Total Billed Charges,65% of Total Billed Charges,365.8,68,,292.64,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.59,20,,86.072,Percent of Total Billed Charges,20% of Total Billed Charges,107.59,20,,86.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.59,20,,86.072,Percent of Total Billed Charges,20% of Total Billed Charges,107.59,20,,86.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,430.35,80,,344.28,Percent of Total Billed Charges,80% of Total Billed Charges,457.25,85,,365.8,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.59,457.25,
NF-Methenamine Mandelate Oral Tablet 1GM,3061469,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
NF-Melatonin Oral Tablet 10MG,3061471,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Solifenacin Succinate Oral Tablet 5MG,3061474,CDM,250,RC,,,Outpatient,,,41,20.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,53.67,
NF-Nortriptyline Oral Capsule 25MG,3061476,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Symbicort Inh Aer Liq 160MCG-4.5MCG,3061477,CDM,250,RC,,,Outpatient,,,137,68.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.05,65,,71.24,Percent of Total Billed Charges,65% of Total Billed Charges,89.05,65,,71.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,89.05,
NF-Wixela Inhub Inhalation Disk 100/50,3061478,CDM,250,RC,,,Outpatient,,,18,9.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.7,65,,9.36,Percent of Total Billed Charges,65% of Total Billed Charges,11.7,65,,9.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,53.67,
NF-Catapres-TTS-3 TD Patch ER 0.3MG/24hr,3061480,CDM,250,RC,,,Outpatient,,,610,305.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122,20,,97.6,Percent of Total Billed Charges,20% of Total Billed Charges,122,20,,97.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122,20,,97.6,Percent of Total Billed Charges,20% of Total Billed Charges,122,20,,97.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,396.5,65,,317.2,Percent of Total Billed Charges,65% of Total Billed Charges,396.5,65,,317.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,396.5,
NF-Zaleplon Oral Capsule 10MG,3061481,CDM,250,RC,,,Outpatient,,,11,5.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,53.67,
NURSING COMMUNICATION - TED HOSE,3061483,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-NAC Oral Capsule 600MG,3061485,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Micardis Tablet 80MG,3061489,CDM,250,RC,,,Outpatient,,,16,8.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,53.67,
NF-Tradjenta Oral Tablet 5MG,3061490,CDM,250,RC,,,Outpatient,,,63,31.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,53.67,
NF-Biotene Dry Mouth Dental Gum,3061495,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Levothyroxine Oral Tablet 150MCG,3061501,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
KEDRAB INJ [150 IU/ML] SDV *IM* 10 ML,3061502,CDM,258,RC,90377,HCPCS,Outpatient,,,4500,2250.00,,2925,65,,2340,Percent of Total Billed Charges,65% of Total Billed Charges,3000,68,,2400,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,900,20,,720,Percent of Total Billed Charges,20% of Total Billed Charges,900,20,,720,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,900,20,,720,Percent of Total Billed Charges,20% of Total Billed Charges,900,20,,720,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2925,65,,2340,Percent of Total Billed Charges,65% of Total Billed Charges,2925,65,,2340,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,3000,
NF-RizatriptanBenzoate Disintegrat Tab 1,3061503,CDM,250,RC,,,Outpatient,,,99,49.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.35,65,,51.48,Percent of Total Billed Charges,65% of Total Billed Charges,64.35,65,,51.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.8,64.35,
NF-Coreg Tablet 25MG,3061504,CDM,250,RC,,,Outpatient,,,25,12.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,53.67,
ceFAZolin/NS IVPB : 2000MG/100ML,3061505,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Tiger Balm Topical Ointment,3061506,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Menthol Topical Gel 8%,3061507,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Simbrinza Ophthalmic Suspension 0.2%-,3061508,CDM,250,RC,,,Outpatient,,,93,46.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,20,,14.88,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,20,,14.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,20,,14.88,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,20,,14.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.45,65,,48.36,Percent of Total Billed Charges,65% of Total Billed Charges,60.45,65,,48.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,60.45,
NF-Errin Oral Tablet 0.35MG,3061509,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
ceFAZolin INJ [2000 MG],3061511,CDM,258,RC,J0690,HCPCS,Outpatient,,,37.13,18.57,,24.13,65,,19.304,Percent of Total Billed Charges,65% of Total Billed Charges,25.25,68,,20.2,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.43,20,,5.944,Percent of Total Billed Charges,20% of Total Billed Charges,7.43,20,,5.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.43,20,,5.944,Percent of Total Billed Charges,20% of Total Billed Charges,7.43,20,,5.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.13,65,,19.304,Percent of Total Billed Charges,65% of Total Billed Charges,24.13,65,,19.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.43,53.67,
NF-Mexiletine HCl Capsule 150MG,3061512,CDM,250,RC,,,Outpatient,,,2,1.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,53.67,
NF-Biofreeze Cool the Pain Cream 10%,3061513,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLINDAMYCIN/D5W [600MG/50ML] PREMIXED,3061514,CDM,636,RC,J0736,HCPCS,Outpatient,,,37.43,18.72,,,,,,Other,Not Seperately Reimbuasble,25.45,68,,20.36,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.49,20,,5.992,Percent of Total Billed Charges,20% of Total Billed Charges,7.49,20,,5.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.49,20,,5.992,Percent of Total Billed Charges,20% of Total Billed Charges,7.49,20,,5.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.94,80,,23.952,Percent of Total Billed Charges,80% of Total Billed Charges,31.82,85,,25.456,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.49,31.82,
MethylPREDNISolone Ace INJ SUSP[40MG/ML],3061516,CDM,258,RC,J1010,HCPCS,Outpatient,,,40.93,20.47,,26.6,65,,21.28,Percent of Total Billed Charges,65% of Total Billed Charges,27.83,68,,22.264,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.19,20,,6.552,Percent of Total Billed Charges,20% of Total Billed Charges,8.19,20,,6.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.19,20,,6.552,Percent of Total Billed Charges,20% of Total Billed Charges,8.19,20,,6.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.6,65,,21.28,Percent of Total Billed Charges,65% of Total Billed Charges,26.6,65,,21.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.19,53.67,
NF-Entresto Oral Tablet 97MG-103MG,3061519,CDM,250,RC,,,Outpatient,,,40,20.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,65,,20.8,Percent of Total Billed Charges,65% of Total Billed Charges,26,65,,20.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,53.67,
NF-Losartan/Hctz Oral Tablet 50MG-12.5MG,3061521,CDM,250,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
BACITRACIN OINT [14 GM],3061522,CDM,250,RC,,,Outpatient,,,8.3,4.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,20,,1.328,Percent of Total Billed Charges,20% of Total Billed Charges,1.66,20,,1.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,20,,1.328,Percent of Total Billed Charges,20% of Total Billed Charges,1.66,20,,1.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,65,,4.32,Percent of Total Billed Charges,65% of Total Billed Charges,5.4,65,,4.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,53.67,
NF-ARIPiprazole Oral Tablet 20MG,3061523,CDM,250,RC,,,Outpatient,,,135,67.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,20,,21.6,Percent of Total Billed Charges,20% of Total Billed Charges,27,20,,21.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,20,,21.6,Percent of Total Billed Charges,20% of Total Billed Charges,27,20,,21.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.75,65,,70.2,Percent of Total Billed Charges,65% of Total Billed Charges,87.75,65,,70.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,87.75,
NF-Desvenlafaxine Succinate Tab ER 25MG,3061524,CDM,250,RC,,,Outpatient,,,34,17.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.1,65,,17.68,Percent of Total Billed Charges,65% of Total Billed Charges,22.1,65,,17.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,53.67,
NF-Lunesta Tablet 3MG,3061525,CDM,250,RC,,,Outpatient,,,71,35.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.15,65,,36.92,Percent of Total Billed Charges,65% of Total Billed Charges,46.15,65,,36.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,53.67,
NF-Ozempic SubQ Soln 2MG/3ML,3061527,CDM,250,RC,,,Outpatient,,,1162,581.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.4,20,,185.92,Percent of Total Billed Charges,20% of Total Billed Charges,232.4,20,,185.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.4,20,,185.92,Percent of Total Billed Charges,20% of Total Billed Charges,232.4,20,,185.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,755.3,65,,604.24,Percent of Total Billed Charges,65% of Total Billed Charges,755.3,65,,604.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,755.3,
NF-Terazosin Oral Capsule 5MG,3061528,CDM,250,RC,,,Outpatient,,,4,2.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,53.67,
NF-Solifenacin Succinate Oral Tablet 5MG,3061530,CDM,250,RC,,,Outpatient,,,41,20.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,53.67,
NF-fluvoxaMINE Maleate Tablet 100MG,3061531,CDM,250,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
NF-fluvoxaMINE Maleate Tablet 100MG,3061532,CDM,250,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
NF-Stribild Oral Tablet,3061535,CDM,250,RC,,,Outpatient,,,501,250.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.2,20,,80.16,Percent of Total Billed Charges,20% of Total Billed Charges,100.2,20,,80.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.2,20,,80.16,Percent of Total Billed Charges,20% of Total Billed Charges,100.2,20,,80.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.65,65,,260.52,Percent of Total Billed Charges,65% of Total Billed Charges,325.65,65,,260.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,325.65,
NF-Levemir Subcutaneous Solution 100U/1M,3061536,CDM,250,RC,,,Outpatient,,,38,19.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,53.67,
WOMEN'S PROBIOTIC [90 BILLION CFU]-NF,3061537,CDM,350,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,407,
NF-Co Q-10 Capsule 50MG,3061538,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Losartan/Hctz Oral Tablet 50MG-12.5MG,3061539,CDM,250,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3061540,CDM,250,RC,,,Outpatient,,,435,217.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87,20,,69.6,Percent of Total Billed Charges,20% of Total Billed Charges,87,20,,69.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87,20,,69.6,Percent of Total Billed Charges,20% of Total Billed Charges,87,20,,69.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.75,65,,226.2,Percent of Total Billed Charges,65% of Total Billed Charges,282.75,65,,226.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,282.75,
NF-Vraylar Oral Capsule 1.5MG,3061543,CDM,250,RC,,,Outpatient,,,165,82.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.25,65,,85.8,Percent of Total Billed Charges,65% of Total Billed Charges,107.25,65,,85.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,107.25,
SIMVASTATIN (ZOCOR) TAB [80 MG]- (NF),3061545,CDM,637,RC,,,Outpatient,,,14.76,7.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,20,,2.36,Percent of Total Billed Charges,20% of Total Billed Charges,2.95,20,,2.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,20,,2.36,Percent of Total Billed Charges,20% of Total Billed Charges,2.95,20,,2.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.59,65,,7.672,Percent of Total Billed Charges,65% of Total Billed Charges,9.59,65,,7.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,53.67,
NF-ARIPiprazole Oral Tablet 5MG,3061546,CDM,250,RC,,,Outpatient,,,96,48.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.4,65,,49.92,Percent of Total Billed Charges,65% of Total Billed Charges,62.4,65,,49.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,62.4,
NF-tacrolimus Topical Ointment 0.1%,3061548,CDM,250,RC,,,Outpatient,,,12,6.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,53.67,
NF-Triamcinolone Acetonide Cream 0.1%,3061549,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Lisinopril/HCTZ Tab 20MG-25MG,3061550,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Linzess Oral Capsule 72MCG,3061554,CDM,250,RC,,,Outpatient,,,64,32.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.6,65,,33.28,Percent of Total Billed Charges,65% of Total Billed Charges,41.6,65,,33.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,53.67,
NF-Vyzulta Ophthalmic Solution 0.024%,3061557,CDM,250,RC,,,Outpatient,,,367,183.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.4,20,,58.72,Percent of Total Billed Charges,20% of Total Billed Charges,73.4,20,,58.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.4,20,,58.72,Percent of Total Billed Charges,20% of Total Billed Charges,73.4,20,,58.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.55,65,,190.84,Percent of Total Billed Charges,65% of Total Billed Charges,238.55,65,,190.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,238.55,
NF-Multivitamin Tablet,3061558,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Entresto Oral Tablet 49MG-51MG,3061559,CDM,250,RC,,,Outpatient,,,41,20.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,53.67,
NF-Centrum Silver Women 50+ Tab,3061560,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vyzulta Ophthalmic Solution 0.024%,3061561,CDM,250,RC,,,Outpatient,,,367,183.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.4,20,,58.72,Percent of Total Billed Charges,20% of Total Billed Charges,73.4,20,,58.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.4,20,,58.72,Percent of Total Billed Charges,20% of Total Billed Charges,73.4,20,,58.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.55,65,,190.84,Percent of Total Billed Charges,65% of Total Billed Charges,238.55,65,,190.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,238.55,
NF-Soliqua SC Solution 100U-33MCG/1ML,3061562,CDM,250,RC,,,Outpatient,,,213,106.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.6,20,,34.08,Percent of Total Billed Charges,20% of Total Billed Charges,42.6,20,,34.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.6,20,,34.08,Percent of Total Billed Charges,20% of Total Billed Charges,42.6,20,,34.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.45,65,,110.76,Percent of Total Billed Charges,65% of Total Billed Charges,138.45,65,,110.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.6,138.45,
NF-Xtandi Oral Tablet 80MG,3061563,CDM,250,RC,,,Outpatient,,,859,429.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.8,20,,137.44,Percent of Total Billed Charges,20% of Total Billed Charges,171.8,20,,137.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.8,20,,137.44,Percent of Total Billed Charges,20% of Total Billed Charges,171.8,20,,137.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,558.35,65,,446.68,Percent of Total Billed Charges,65% of Total Billed Charges,558.35,65,,446.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,558.35,
NF-Xtandi Oral Tablet 80MG,3061564,CDM,250,RC,,,Outpatient,,,859,429.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.8,20,,137.44,Percent of Total Billed Charges,20% of Total Billed Charges,171.8,20,,137.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.8,20,,137.44,Percent of Total Billed Charges,20% of Total Billed Charges,171.8,20,,137.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,558.35,65,,446.68,Percent of Total Billed Charges,65% of Total Billed Charges,558.35,65,,446.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,558.35,
NF-hydrOXYzine Pamoate Oral Cap 25MG,3061565,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Midodrine HCl Tablet 10MG,3061566,CDM,250,RC,,,Outpatient,,,14,7.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,53.67,
NF-Escitalopram Oral Tablet 20MG,3061567,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-fentaNYL TD Patch ER 37.5MG,3061568,CDM,250,RC,,,Outpatient,,,195,97.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39,20,,31.2,Percent of Total Billed Charges,20% of Total Billed Charges,39,20,,31.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39,20,,31.2,Percent of Total Billed Charges,20% of Total Billed Charges,39,20,,31.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.75,65,,101.4,Percent of Total Billed Charges,65% of Total Billed Charges,126.75,65,,101.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39,126.75,
NF-PreserVision Areds 2 Oral Liq Cap,3061569,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Simvastatin Oral Tablet 40MG,3061570,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Triamcinolone Acetonide Cream 0.1%,3061571,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Estrace Vaginal Cream 0.1MG/1GM,3061572,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Travatan Z Ophthalmic Solution 0.004%,3061573,CDM,250,RC,,,Outpatient,,,354,177.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.8,20,,56.64,Percent of Total Billed Charges,20% of Total Billed Charges,70.8,20,,56.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.8,20,,56.64,Percent of Total Billed Charges,20% of Total Billed Charges,70.8,20,,56.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230.1,65,,184.08,Percent of Total Billed Charges,65% of Total Billed Charges,230.1,65,,184.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,230.1,
NF-Myrbetriq Oral Tablet 50MG,3061574,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Solifenacin Succinate Oral Tablet 5MG,3061575,CDM,250,RC,,,Outpatient,,,41,20.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,53.67,
NF-Vitamin D3 Oral Cap 125MCG,3061576,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Nature's Blend Turmeric Cap 500MG,3061580,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-busPIRone Hydrochloride Oral Tablet 1,3061581,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Nurtec ODT Oral Dis Tablet 75MG,3061582,CDM,250,RC,,,Outpatient,,,449,224.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.8,20,,71.84,Percent of Total Billed Charges,20% of Total Billed Charges,89.8,20,,71.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.8,20,,71.84,Percent of Total Billed Charges,20% of Total Billed Charges,89.8,20,,71.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.85,65,,233.48,Percent of Total Billed Charges,65% of Total Billed Charges,291.85,65,,233.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,291.85,
NF-busPIRone Oral Tablet 10MG,3061583,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
NF-busPIRone Oral Tablet 10MG,3061584,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
NF-Nystatin Not Applicable Powder 5BILLI,3061585,CDM,250,RC,,,Outpatient,,,41681,20840.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8336.2,20,,6668.96,Percent of Total Billed Charges,20% of Total Billed Charges,8336.2,20,,6668.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8336.2,20,,6668.96,Percent of Total Billed Charges,20% of Total Billed Charges,8336.2,20,,6668.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27092.65,65,,21674.12,Percent of Total Billed Charges,65% of Total Billed Charges,27092.65,65,,21674.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,27092.65,
TWOCAL HN NUTRITION [2.0 CAL]- (NF),3061587,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NG TUBE WATER FLUSH,3061588,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Biofreeze Topical Gel 4%,3061590,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Unisom Tablet 25MG,3061593,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
VITAMIN D+ IMMUNE COMPLEX+PROBIOTIC-(NF),3061594,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALCIUM CITRATE+D3 [650MG/25MCG]-(NF),3061595,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Breztri Aerosphere Inh Aer Liq,3061596,CDM,250,RC,,,Outpatient,,,217,108.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,20,,34.72,Percent of Total Billed Charges,20% of Total Billed Charges,43.4,20,,34.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,20,,34.72,Percent of Total Billed Charges,20% of Total Billed Charges,43.4,20,,34.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.05,65,,112.84,Percent of Total Billed Charges,65% of Total Billed Charges,141.05,65,,112.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,141.05,
NALOXONE(NARCAN)NASAL SPRAY [4 MG/0.1ML],3061597,CDM,250,RC,,,Outpatient,,,112.5,56.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,20,,18,Percent of Total Billed Charges,20% of Total Billed Charges,22.5,20,,18,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,20,,18,Percent of Total Billed Charges,20% of Total Billed Charges,22.5,20,,18,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.13,65,,58.504,Percent of Total Billed Charges,65% of Total Billed Charges,73.13,65,,58.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,73.13,
NF-Sirolimus Oral Tablet 0.5MG,3061599,CDM,250,RC,,,Outpatient,,,25,12.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,53.67,
NF-Tacrolimus Oral Capsule 0.5MG,3061600,CDM,250,RC,,,Outpatient,,,6,3.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,53.67,
INF-CROTALIDAE POLY/NS IVPB:4VIALS/250ML,3061601,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
cefTRIAXone [750 MG] IM,3061603,CDM,250,RC,J0696,HCPCS,Outpatient,,,51.5,25.75,,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,68,,28.016,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,53.67,
NF-PHENobarbital Tablet 97.2MG,3061605,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-PHENobarbital Tablet 97.2MG,3061606,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-ARIPiprazole Oral Tablet 2MG,3061607,CDM,250,RC,,,Outpatient,,,96,48.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.4,65,,49.92,Percent of Total Billed Charges,65% of Total Billed Charges,62.4,65,,49.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,62.4,
NF-Benazepril Oral Tablet 40MG,3061608,CDM,250,RC,,,Outpatient,,,4,2.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,53.67,
NF-Benazepril HCl Tablet 40MG,3061609,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Breztri Aerosphere Inh Aer Liq,3061610,CDM,250,RC,,,Outpatient,,,217,108.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,20,,34.72,Percent of Total Billed Charges,20% of Total Billed Charges,43.4,20,,34.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,20,,34.72,Percent of Total Billed Charges,20% of Total Billed Charges,43.4,20,,34.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.05,65,,112.84,Percent of Total Billed Charges,65% of Total Billed Charges,141.05,65,,112.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,141.05,
OFEV (NINTEDANIB) CAP [100 MG]- NF,3061612,CDM,250,RC,,,Outpatient,,,779,389.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.8,20,,124.64,Percent of Total Billed Charges,20% of Total Billed Charges,155.8,20,,124.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.8,20,,124.64,Percent of Total Billed Charges,20% of Total Billed Charges,155.8,20,,124.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.35,65,,405.08,Percent of Total Billed Charges,65% of Total Billed Charges,506.35,65,,405.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,506.35,
NF-Olmesartan Medoxomil Oral Tablet 40MG,3061613,CDM,250,RC,,,Outpatient,,,28,14.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,65,,14.56,Percent of Total Billed Charges,65% of Total Billed Charges,18.2,65,,14.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,53.67,
NF-Ofev Oral Capsule 100MG,3061614,CDM,250,RC,,,Outpatient,,,779,389.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.8,20,,124.64,Percent of Total Billed Charges,20% of Total Billed Charges,155.8,20,,124.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.8,20,,124.64,Percent of Total Billed Charges,20% of Total Billed Charges,155.8,20,,124.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.35,65,,405.08,Percent of Total Billed Charges,65% of Total Billed Charges,506.35,65,,405.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,506.35,
SMZ/TMP ORAL SUSP [200MG-40MG/5ML],3061615,CDM,250,RC,,,Outpatient,,,37.06,18.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,20,,5.928,Percent of Total Billed Charges,20% of Total Billed Charges,7.41,20,,5.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,20,,5.928,Percent of Total Billed Charges,20% of Total Billed Charges,7.41,20,,5.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,65,,19.272,Percent of Total Billed Charges,65% of Total Billed Charges,24.09,65,,19.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,53.67,
NF-Osteo Bi-Flex Oral Tablet 200MG-250MG,3061617,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-MegaRed ES Krill Oil Liq Cap 500MG,3061618,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-MegaRed ES Krill Oil Liq Cap 500MG,3061619,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-High Potency Multivitamin Oral Tablet,3061620,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Ciclopirox Topical Shampoo 1%,3061621,CDM,250,RC,,,Outpatient,,,2,1.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,53.67,
NF-Clobetasol Propionate Solution 0.05%,3061622,CDM,250,RC,,,Outpatient,,,12,6.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,53.67,
NF-Restasis Ophthalmic Emulsion 0.05%,3061623,CDM,250,RC,,,Outpatient,,,38,19.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,53.67,
NF-Latuda Oral Tablet 60MG,3061624,CDM,250,RC,,,Outpatient,,,170,85.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.5,65,,88.4,Percent of Total Billed Charges,65% of Total Billed Charges,110.5,65,,88.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,110.5,
NF-Vitamin D3 Oral Tablet 50MCG,3061625,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Alphagan P Opthamalic Solution  0.1%,3061626,CDM,250,RC,,,Outpatient,,,140,70.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,20,,22.4,Percent of Total Billed Charges,20% of Total Billed Charges,28,20,,22.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,20,,22.4,Percent of Total Billed Charges,20% of Total Billed Charges,28,20,,22.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,65,,72.8,Percent of Total Billed Charges,65% of Total Billed Charges,91,65,,72.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,91,
NF-Milk Of Magnesia Oral Susp 2400MG/30M,3061627,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Simvastatin Oral Tablet 40MG,3061629,CDM,250,RC,,,Outpatient,,,14,7.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,53.67,
NF-Brinzolamide Ophthalmic Susp 1%,3061630,CDM,250,RC,,,Outpatient,,,117,58.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.4,20,,18.72,Percent of Total Billed Charges,20% of Total Billed Charges,23.4,20,,18.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.4,20,,18.72,Percent of Total Billed Charges,20% of Total Billed Charges,23.4,20,,18.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.05,65,,60.84,Percent of Total Billed Charges,65% of Total Billed Charges,76.05,65,,60.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.4,76.05,
NF-Drisdol Oral LiquidFilledCapsule 5000,3061633,CDM,250,RC,,,Outpatient,,,10,5.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,53.67,
NF-Biotin Oral Tablet 5000MCG,3061639,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Estradiol Vaginal Cream 0.1MG/1GM,3061640,CDM,250,RC,,,Outpatient,,,8,4.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,53.67,
NF-Vitamin C Tablet 1000MG,3061642,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-hydrOXYzine Pamoate Oral Cap 25MG,3061645,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-fluPHENAZine Hydrochloride Tablet 10M,3061648,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vitamin D Oral Capsule 50000IU,3061649,CDM,250,RC,,,Outpatient,,,4,2.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,53.67,
NF-Benazepril HCl Tablet 20MG,3061651,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Fycompa Oral Tablet 12MG,3061654,CDM,250,RC,,,Outpatient,,,147,73.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.4,20,,23.52,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,20,,23.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.4,20,,23.52,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,20,,23.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.55,65,,76.44,Percent of Total Billed Charges,65% of Total Billed Charges,95.55,65,,76.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.4,95.55,
NF-Glycopyrrolate Soln 1MG/5ML,3061655,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Vimpat Oral Tablet 100MG,3061656,CDM,250,RC,,,Outpatient,,,66,33.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.2,20,,10.56,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,20,,10.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.2,20,,10.56,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,20,,10.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.9,65,,34.32,Percent of Total Billed Charges,65% of Total Billed Charges,42.9,65,,34.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.2,53.67,
NF-cloBAZam Oral Suspension 2.5MG/1ML,3061658,CDM,250,RC,,,Outpatient,,,27,13.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,53.67,
NF-Phos Lo Oral Capsule 667MG,3061661,CDM,250,RC,,,Outpatient,,,2,1.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,53.67,
NF-Dorzolamide HCl-Timolol Ophth Soln,3061662,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Lansoprazole Disintegrating Tab DR 30,3061663,CDM,250,RC,,,Outpatient,,,47,23.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,53.67,
NF-Ondansetron Oral Solution 4MG/5ML,3061665,CDM,250,RC,,,Outpatient,,,14,7.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,53.67,
NF-DULoxetine HCl Cap DR 20MG,3061666,CDM,250,RC,,,Outpatient,,,20,10.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,53.67,
NF-Doxazosin Oral Tablet 1MG,3061671,CDM,250,RC,,,Outpatient,,,4,2.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,53.67,
NF-Doxazosin Oral Tablet 1MG,3061672,CDM,250,RC,,,Outpatient,,,4,2.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,53.67,
NF-Premarin Oral Tablet 0.625MG,3061673,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Lenvima Oral Capsule 4MG;10MG,3061674,CDM,250,RC,,,Outpatient,,,970,485.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194,20,,155.2,Percent of Total Billed Charges,20% of Total Billed Charges,194,20,,155.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194,20,,155.2,Percent of Total Billed Charges,20% of Total Billed Charges,194,20,,155.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,630.5,65,,504.4,Percent of Total Billed Charges,65% of Total Billed Charges,630.5,65,,504.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,630.5,
NF-Olmesartan Medoxomil Oral Tablet 40MG,3061675,CDM,250,RC,,,Outpatient,,,28,14.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,65,,14.56,Percent of Total Billed Charges,65% of Total Billed Charges,18.2,65,,14.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,53.67,
NF-Gabapentin Oral Capsule 100MG,3061676,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Rivastigmine Tartrate Oral Capsule 3M,3061677,CDM,250,RC,,,Outpatient,,,12,6.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,53.67,
NF-Vitamin E Oral Liq Cap 180MG,3061678,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Alpha-Lipoic Acid Oral Capsule 600MG,3061679,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Ozempic SubQ Soln 2MG/3ML,3061681,CDM,250,RC,,,Outpatient,,,1162,581.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.4,20,,185.92,Percent of Total Billed Charges,20% of Total Billed Charges,232.4,20,,185.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.4,20,,185.92,Percent of Total Billed Charges,20% of Total Billed Charges,232.4,20,,185.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,755.3,65,,604.24,Percent of Total Billed Charges,65% of Total Billed Charges,755.3,65,,604.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,755.3,
NF-One-A-Day Women's 50+,3061682,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Prochlorperazine Maleate AvPak Tab 10,3061683,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
ISOSOURCE[1.5 KCAL/ML] LIQUID(250 ML)-NF,3061685,CDM,250,RC,,,Outpatient,,,0.02,0.01,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,65,,0.008,Percent of Total Billed Charges,65% of Total Billed Charges,0.01,65,,0.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,53.67,
NF-Tikosyn Oral Capsule 125MCG,3061686,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
METAFOLBIC PLUS CAPLET-(NF),3061687,CDM,250,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
NF-fluPHENAZine HCl Tablet 10MG,3061688,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
NF-Mounjaro SubQ Soln 5MG/0.5ML,3061689,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Janumet XR Oral Tab ER 1000MG-50MG,3061690,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Vascepa Oral Liquid Filled Cap 1GM,3061691,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-busPIRone Oral Tablet 10MG,3061692,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
NF-Mycophenolate Mofetil Oral Tablet 500,3061693,CDM,250,RC,,,Outpatient,,,23,11.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,65,,11.96,Percent of Total Billed Charges,65% of Total Billed Charges,14.95,65,,11.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,53.67,
NF-Prochlorperazine Tablet 5mg,3061694,CDM,250,RC,,,Outpatient,,,3,1.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,53.67,
NF-Mycophenolate Mofetil Oral Tablet 500,3061696,CDM,250,RC,,,Outpatient,,,23,11.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,65,,11.96,Percent of Total Billed Charges,65% of Total Billed Charges,14.95,65,,11.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,53.67,
OMEGA-3-ACID ETHYL ESTERS [1 GRAM]-(NF),3061702,CDM,637,RC,,,Outpatient,,,6,3.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,53.67,
NF-Pomalyst Oral Capsule 4MG,3061703,CDM,250,RC,,,Outpatient,,,3932,1966.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.4,20,,629.12,Percent of Total Billed Charges,20% of Total Billed Charges,786.4,20,,629.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.4,20,,629.12,Percent of Total Billed Charges,20% of Total Billed Charges,786.4,20,,629.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2555.8,65,,2044.64,Percent of Total Billed Charges,65% of Total Billed Charges,2555.8,65,,2044.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2555.8,
ELDERBERRY CHEW GUMMIES W/ VIT C&D-(NF),3061706,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Breo Ellipta Inhalation Powder,3061708,CDM,250,RC,,,Outpatient,,,24,12.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,53.67,
NF-Lactulose Solution 10GM/15ML,3061709,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Phenergan Injection Solution 25MG/1ML,3061712,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3061713,CDM,250,RC,,,Outpatient,,,474,237.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.1,65,,246.48,Percent of Total Billed Charges,65% of Total Billed Charges,308.1,65,,246.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,308.1,
NF-Breo Ellipta Inhalation Powder,3061714,CDM,250,RC,,,Outpatient,,,24,12.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,53.67,
NF-Arnuity Ellipta Inh Pwd 100MCG/1ACT,3061717,CDM,250,RC,,,Outpatient,,,25,12.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,53.67,
NF-Vitamin B Complex Tablet,3061718,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Melatonin Gummies Chew Tab 1MG,3061720,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Hyzaar Oral Tablet 100MG-25MG,3061721,CDM,250,RC,,,Outpatient,,,23,11.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,4.6,20,,3.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,65,,11.96,Percent of Total Billed Charges,65% of Total Billed Charges,14.95,65,,11.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,53.67,
NF-Losartan/Hctz Oral Tablet 100MG-25MG,3061722,CDM,250,RC,,,Outpatient,,,9,4.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,53.67,
NF-Tylenol PM Extra Strength Tablet,3061723,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Omeprazole Oral Tablet DR 20MG,3061724,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Pioglitazone HCl Oral Tablet 15MG,3061726,CDM,250,RC,,,Outpatient,,,21,10.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,53.67,
NF-Venlafaxine HCl AvPak Oral Cap ER 37.,3061727,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Losartan/Hctz Oral Tablet 50MG-12.5MG,3061728,CDM,250,RC,,,Outpatient,,,7,3.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,53.67,
NF-Rosuvastatin Calcium Oral Tablet 10MG,3061729,CDM,250,RC,,,Outpatient,,,26,13.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,53.67,
NF-Thyroid Tablet 90MG,3061730,CDM,250,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
NF-Opsumit Oral Tablet 10MG,3061734,CDM,250,RC,,,Outpatient,,,1516,758.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.2,20,,242.56,Percent of Total Billed Charges,20% of Total Billed Charges,303.2,20,,242.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.2,20,,242.56,Percent of Total Billed Charges,20% of Total Billed Charges,303.2,20,,242.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,985.4,65,,788.32,Percent of Total Billed Charges,65% of Total Billed Charges,985.4,65,,788.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,985.4,
NF-Uptravi Oral Tablet 1600MCG,3061735,CDM,250,RC,,,Outpatient,,,1374,687.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.8,20,,219.84,Percent of Total Billed Charges,20% of Total Billed Charges,274.8,20,,219.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.8,20,,219.84,Percent of Total Billed Charges,20% of Total Billed Charges,274.8,20,,219.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,893.1,65,,714.48,Percent of Total Billed Charges,65% of Total Billed Charges,893.1,65,,714.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,893.1,
NF-Adempas Oral Tablet 2.5MG,3061736,CDM,250,RC,,,Outpatient,,,553,276.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.6,20,,88.48,Percent of Total Billed Charges,20% of Total Billed Charges,110.6,20,,88.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.6,20,,88.48,Percent of Total Billed Charges,20% of Total Billed Charges,110.6,20,,88.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.45,65,,287.56,Percent of Total Billed Charges,65% of Total Billed Charges,359.45,65,,287.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,359.45,
NF-Tyvaso DPI Inhalation Powder 48MCG,3061738,CDM,250,RC,,,Outpatient,,,739,369.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.8,20,,118.24,Percent of Total Billed Charges,20% of Total Billed Charges,147.8,20,,118.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.8,20,,118.24,Percent of Total Billed Charges,20% of Total Billed Charges,147.8,20,,118.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480.35,65,,384.28,Percent of Total Billed Charges,65% of Total Billed Charges,480.35,65,,384.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,480.35,
NF-Tyvaso DPI Inhalation Powder 32MCG,3061739,CDM,250,RC,,,Outpatient,,,739,369.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.8,20,,118.24,Percent of Total Billed Charges,20% of Total Billed Charges,147.8,20,,118.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.8,20,,118.24,Percent of Total Billed Charges,20% of Total Billed Charges,147.8,20,,118.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480.35,65,,384.28,Percent of Total Billed Charges,65% of Total Billed Charges,480.35,65,,384.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,480.35,
SILDENAFIL TAB [20 MG]-(NF),3061741,CDM,250,RC,,,Outpatient,,,11.5,5.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.3,20,,1.84,Percent of Total Billed Charges,20% of Total Billed Charges,2.3,20,,1.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.3,20,,1.84,Percent of Total Billed Charges,20% of Total Billed Charges,2.3,20,,1.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.48,65,,5.984,Percent of Total Billed Charges,65% of Total Billed Charges,7.48,65,,5.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.3,53.67,
SILDENAFIL TAB [20 MG]- (NF),3061742,CDM,250,RC,,,Outpatient,,,5.75,2.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,65,,2.992,Percent of Total Billed Charges,65% of Total Billed Charges,3.74,65,,2.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,53.67,
NF-Uroxatral Oral Tablet ER 10MG,3061743,CDM,250,RC,,,Outpatient,,,101,50.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.2,20,,16.16,Percent of Total Billed Charges,20% of Total Billed Charges,20.2,20,,16.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.2,20,,16.16,Percent of Total Billed Charges,20% of Total Billed Charges,20.2,20,,16.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.65,65,,52.52,Percent of Total Billed Charges,65% of Total Billed Charges,65.65,65,,52.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.2,65.65,
NF-Alfuzosin Hydrochloride Oral Tab ER 1,3061745,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Rybelsus Oral Tablet 3MG,3061746,CDM,250,RC,,,Outpatient,,,116,58.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,65,,60.32,Percent of Total Billed Charges,65% of Total Billed Charges,75.4,65,,60.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,75.4,
NF-busPIRone Oral Tablet 5MG,3061747,CDM,250,RC,,,Outpatient,,,2,1.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,53.67,
BUSPIRONE HCL TAB [5 MG],3061748,CDM,250,RC,,,Outpatient,,,5.75,2.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,1.15,20,,0.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,65,,2.992,Percent of Total Billed Charges,65% of Total Billed Charges,3.74,65,,2.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,53.67,
NF-Turmeric Oral Capsule 500MG,3061750,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Sore Throat Spray 1.4%,3061751,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
METOCLOPRAMIDE/NS IVPB: 10 MG/50ML,3061752,CDM,361,RC,J2765,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PRESERVISION AREDS VITAMIN SOFT GEL-(NF),3061753,CDM,350,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,407,
NF-Sorbitol Solution 70%,3061754,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-fentaNYL TD Patch ER 37.5MG,3061757,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Brilinta Oral Tablet 60MG,3061758,CDM,250,RC,,,Outpatient,,,27,13.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,53.67,
NF-Rybelsus Oral Tablet 3MG,3061759,CDM,250,RC,,,Outpatient,,,116,58.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,65,,60.32,Percent of Total Billed Charges,65% of Total Billed Charges,75.4,65,,60.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,75.4,
NF-Dulcolax Liquid Susp 1200MG/15ML,3061760,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LIDOCAINE  INJ 1% [50MG/5ML] PF,3061761,CDM,258,RC,J2003,HCPCS,Outpatient,,,5.3,2.65,,3.45,65,,2.76,Percent of Total Billed Charges,65% of Total Billed Charges,3.6,68,,2.88,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,20,,0.848,Percent of Total Billed Charges,20% of Total Billed Charges,1.06,20,,0.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,20,,0.848,Percent of Total Billed Charges,20% of Total Billed Charges,1.06,20,,0.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,65,,2.76,Percent of Total Billed Charges,65% of Total Billed Charges,3.45,65,,2.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,53.67,
NF-Alfuzosin Hydrochloride Oral Tab ER 1,3061762,CDM,250,RC,,,Outpatient,,,1,0.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,53.67,
NF-Caplyta Oral Capsule 42MG,3061763,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-CoQ10 Oral Capsule 100MG,3061764,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NF-Tolterodine Tartrate Oral Cap ER 4MG,3061765,CDM,250,RC,,,Outpatient,,,24,12.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,53.67,
NF-Tolterodine Tartrate Oral Cap ER 4MG,3061767,CDM,250,RC,,,Outpatient,,,24,12.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,53.67,
LEVOTHYROXINE INJ [100 MCG/5ML],3061769,CDM,361,RC,J0650,HCPCS,Outpatient,,,322.02,161.01,,209.31,65,,167.448,Percent of Total Billed Charges,65% of Total Billed Charges,218.97,68,,175.176,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.4,20,,51.52,Percent of Total Billed Charges,20% of Total Billed Charges,64.4,20,,51.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.4,20,,51.52,Percent of Total Billed Charges,20% of Total Billed Charges,64.4,20,,51.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.31,65,,167.448,Percent of Total Billed Charges,65% of Total Billed Charges,209.31,65,,167.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.01,50,,128.808,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,218.97,
NF-Rybelsus Oral Tablet 3MG,3061770,CDM,250,RC,,,Outpatient,,,116,58.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,65,,60.32,Percent of Total Billed Charges,65% of Total Billed Charges,75.4,65,,60.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,75.4,
NF-Brilinta Oral Tablet 60MG,3061771,CDM,250,RC,,,Outpatient,,,27,13.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,53.67,
NF-Brilinta Oral Tablet 60MG,3061772,CDM,250,RC,,,Outpatient,,,27,13.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,53.67,
NF-ARIPiprazole Oral Tablet 10MG,3061773,CDM,250,RC,,,Outpatient,,,96,48.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,20,,15.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.4,65,,49.92,Percent of Total Billed Charges,65% of Total Billed Charges,62.4,65,,49.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.2,62.4,
INF-NOREPINEPHRINE/D5W IVPB: 4MG/250 ML,3099996,CDM,258,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CIWA PROCEDURE - BASED ON SCORING GUIDEL,3099997,CDM,250,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
JUST LIKE TEMPLATE   ISC AO/REV CODE 637,3099999,CDM,637,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LIPOSYN 500ML IV,3120003,CDM,258,RC,,,Outpatient,,,187.25,93.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.45,20,,29.96,Percent of Total Billed Charges,20% of Total Billed Charges,37.45,20,,29.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.45,20,,29.96,Percent of Total Billed Charges,20% of Total Billed Charges,37.45,20,,29.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.71,65,,97.368,Percent of Total Billed Charges,65% of Total Billed Charges,121.71,65,,97.368,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.45,121.71,
AMINOSYN 3.5 1M,3120013,CDM,258,RC,J0282,HCPCS,Outpatient,,,142.6,71.30,,92.69,65,,74.152,Percent of Total Billed Charges,65% of Total Billed Charges,96.97,68,,77.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.52,20,,22.816,Percent of Total Billed Charges,20% of Total Billed Charges,28.52,20,,22.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.52,20,,22.816,Percent of Total Billed Charges,20% of Total Billed Charges,28.52,20,,22.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.69,65,,74.152,Percent of Total Billed Charges,65% of Total Billed Charges,92.69,65,,74.152,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.52,96.97,
IV-SC 9 1000 ML,3120283,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IV-NACL 9 500,3120285,CDM,258,RC,,,Outpatient,,,64.89,32.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,53.67,
IV-NACL 0.9% 250ML,3120289,CDM,258,RC,,,Outpatient,,,55.62,27.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,53.67,
IV-DEX 5 500-1522-03,3120291,CDM,258,RC,,,Outpatient,,,58.71,29.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,53.67,
IV-DEX 5 250,3120293,CDM,258,RC,,,Outpatient,,,50.47,25.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,53.67,
IV-DEX 5 500 2B0063Q,3120294,CDM,258,RC,,,Outpatient,,,55.62,27.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,53.67,
IV-DEX 5 500,3120295,CDM,258,RC,,,Outpatient,,,58.71,29.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,53.67,
IV-DEX 5 1M,3120297,CDM,258,RC,,,Outpatient,,,26.88,13.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.47,65,,13.976,Percent of Total Billed Charges,65% of Total Billed Charges,17.47,65,,13.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,53.67,
IV LACT RING 5% DEX,3120299,CDM,258,RC,,,Outpatient,,,61.8,30.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
IV-LACT RINGER 1000,3120301,CDM,258,RC,,,Outpatient,,,61.8,30.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
LIPOSY 200ML IV,3120331,CDM,250,RC,,,Outpatient,,,117.57,58.79,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.51,20,,18.808,Percent of Total Billed Charges,20% of Total Billed Charges,23.51,20,,18.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.51,20,,18.808,Percent of Total Billed Charges,20% of Total Billed Charges,23.51,20,,18.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.42,65,,61.136,Percent of Total Billed Charges,65% of Total Billed Charges,76.42,65,,61.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.51,76.42,
IV SOD CHLOR 0.9% 50ML,3121861,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV DEXTROSE 100ML,3121863,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IF-DEX 5 PF/ADV 100,3121865,CDM,258,RC,,,Outpatient,,,50.47,25.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,10.09,20,,8.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,32.81,65,,26.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.09,53.67,
IV-DEX 5 NACL 1/4 1M,3121867,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IV-DEX 5% SOD CHL0.45% 500 ML,3121868,CDM,258,RC,,,Outpatient,,,64.89,32.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,53.67,
IV-DEX 5 NACL 1/3 1M,3121869,CDM,258,RC,,,Outpatient,,,63.86,31.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,53.67,
IV-DEX 5 NACL 1/2 1M,3121871,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IV-DEX 5 NACL 9 500,3121873,CDM,258,RC,,,Outpatient,,,60.77,30.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.5,65,,31.6,Percent of Total Billed Charges,65% of Total Billed Charges,39.5,65,,31.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.15,53.67,
IV-DEX 5 NACL 9 1M,3121875,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
HYTRIN 2 MG,3121877,CDM,250,RC,,,Outpatient,,,5.82,2.91,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,20,,0.928,Percent of Total Billed Charges,20% of Total Billed Charges,1.16,20,,0.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,20,,0.928,Percent of Total Billed Charges,20% of Total Billed Charges,1.16,20,,0.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.78,65,,3.024,Percent of Total Billed Charges,65% of Total Billed Charges,3.78,65,,3.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,53.67,
PLASMA LYTE DEX 5 1M,3121879,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IV-NORM R DEX 5 1M,3121881,CDM,258,RC,,,Outpatient,,,63.86,31.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,53.67,
KCL 20 MEQ 20 ML,3121883,CDM,258,RC,,,Outpatient,,,13.39,6.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,2.68,20,,2.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,8.7,65,,6.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,53.67,
IV-NACL 45 1M,3121885,CDM,258,RC,,,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,53.67,
IV-NACL 9 MIN BAG 50ML,3121887,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
SOD CHLOR 15000ML,3121889,CDM,637,RC,,,Outpatient,,,12.88,6.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,2.58,20,,2.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.37,65,,6.696,Percent of Total Billed Charges,65% of Total Billed Charges,8.37,65,,6.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.58,53.67,
IV-SOD CHLOR 250MLAD,3121891,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV NACL 0.9% 100ML 2B1302,3121893,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IV-5% DEX 50ML,3121895,CDM,258,RC,,,Outpatient,,,53.56,26.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,53.67,
IV-NACL 9 PF MIN BG 100ML,3121899,CDM,258,RC,,,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,53.67,
IF-DEX 5 NACL 1/4,3121901,CDM,258,RC,,,Outpatient,,,61.8,30.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,53.67,
LEVOTHYROXINE 200MCG,3121903,CDM,250,RC,,,Outpatient,,,50.83,25.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.17,20,,8.136,Percent of Total Billed Charges,20% of Total Billed Charges,10.17,20,,8.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.17,20,,8.136,Percent of Total Billed Charges,20% of Total Billed Charges,10.17,20,,8.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.04,65,,26.432,Percent of Total Billed Charges,65% of Total Billed Charges,33.04,65,,26.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.17,53.67,
KCL 10MEG D5 1/2,3121905,CDM,250,RC,J3480,HCPCS,Outpatient,,,23.9,11.95,,15.54,65,,12.432,Percent of Total Billed Charges,65% of Total Billed Charges,16.25,68,,13,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,20,,3.824,Percent of Total Billed Charges,20% of Total Billed Charges,4.78,20,,3.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,20,,3.824,Percent of Total Billed Charges,20% of Total Billed Charges,4.78,20,,3.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.54,65,,12.432,Percent of Total Billed Charges,65% of Total Billed Charges,15.54,65,,12.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,53.67,
KCL 20MEQ D5 1/2,3121907,CDM,250,RC,J3480,HCPCS,Outpatient,,,19.78,9.89,,12.86,65,,10.288,Percent of Total Billed Charges,65% of Total Billed Charges,13.45,68,,10.76,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.96,20,,3.168,Percent of Total Billed Charges,20% of Total Billed Charges,3.96,20,,3.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.96,20,,3.168,Percent of Total Billed Charges,20% of Total Billed Charges,3.96,20,,3.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.86,65,,10.288,Percent of Total Billed Charges,65% of Total Billed Charges,12.86,65,,10.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.96,53.67,
POTASSIUM 20 MEQ .45NS,3121909,CDM,258,RC,J3480,HCPCS,Outpatient,,,16.27,8.14,,10.58,65,,8.464,Percent of Total Billed Charges,65% of Total Billed Charges,11.06,68,,8.848,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,20,,2.6,Percent of Total Billed Charges,20% of Total Billed Charges,3.25,20,,2.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,20,,2.6,Percent of Total Billed Charges,20% of Total Billed Charges,3.25,20,,2.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.58,65,,8.464,Percent of Total Billed Charges,65% of Total Billed Charges,10.58,65,,8.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,53.67,
POTASSIUM 20MEQ 0.9NS,3121911,CDM,258,RC,J3480,HCPCS,Outpatient,,,24.31,12.16,,15.8,65,,12.64,Percent of Total Billed Charges,65% of Total Billed Charges,16.53,68,,13.224,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.86,20,,3.888,Percent of Total Billed Charges,20% of Total Billed Charges,4.86,20,,3.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.86,20,,3.888,Percent of Total Billed Charges,20% of Total Billed Charges,4.86,20,,3.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.8,65,,12.64,Percent of Total Billed Charges,65% of Total Billed Charges,15.8,65,,12.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.86,53.67,
CALCIUM GLUC 10 % SDV,3121913,CDM,250,RC,,,Outpatient,,,16.48,8.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,53.67,
FOLIC ACID 5MG/ML IV,3121915,CDM,250,RC,,,Outpatient,,,16.48,8.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,53.67,
DOXCYCLINE 100 MG IV,3121917,CDM,250,RC,,,Outpatient,,,85.23,42.62,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.05,20,,13.64,Percent of Total Billed Charges,20% of Total Billed Charges,17.05,20,,13.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.05,20,,13.64,Percent of Total Billed Charges,20% of Total Billed Charges,17.05,20,,13.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.4,65,,44.32,Percent of Total Billed Charges,65% of Total Billed Charges,55.4,65,,44.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.05,55.4,
IV-0.9 ADDV NACL 250,3121919,CDM,258,RC,,,Outpatient,,,63.86,31.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,53.67,
IV 0.9 NACL 25 ML,3121921,CDM,258,RC,,,Outpatient,,,53.56,26.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,53.67,
IV-NACL 0.9% 50 ML SNGL,3121922,CDM,258,RC,,,Outpatient,,,27.66,13.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,5.53,20,,4.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.98,65,,14.384,Percent of Total Billed Charges,65% of Total Billed Charges,17.98,65,,14.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,53.67,
IV-NACL 0.9% 100 ML SNGL,3121924,CDM,258,RC,,,Outpatient,,,55.62,27.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,53.67,
BB PLATELET PROC/STORAGE,4000000,CDM,390,RC,P9019,HCPCS,Outpatient,,,210,105.00,,136.5,65,,109.2,Percent of Total Billed Charges,65% of Total Billed Charges,142.8,68,,114.24,Percent of Total Billed Charges,68% of Total Billed Charges,44,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,42,20,,33.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,65,,109.2,Percent of Total Billed Charges,65% of Total Billed Charges,136.5,65,,109.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,142.8,
DRAW BLOOD,4000001,CDM,300,RC,36415,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,3,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,10.51,
DNA COLLECTION FEE,4000003,CDM,300,RC,36415,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,3,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,17.51,
MHA-TP,4000005,CDM,302,RC,86780,HCPCS,Outpatient,,,75.19,37.60,,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,51.13,68,,40.904,Percent of Total Billed Charges,68% of Total Billed Charges,18.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.6,50,,30.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.04,51.13,
BB PLATELET PHER PROC/STORAG,4000010,CDM,390,RC,P9034,HCPCS,Outpatient,,,396.28,198.14,,257.58,65,,206.064,Percent of Total Billed Charges,65% of Total Billed Charges,269.47,68,,215.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.26,20,,63.408,Percent of Total Billed Charges,20% of Total Billed Charges,79.26,20,,63.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.26,20,,63.408,Percent of Total Billed Charges,20% of Total Billed Charges,79.26,20,,63.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.58,65,,206.064,Percent of Total Billed Charges,65% of Total Billed Charges,257.58,65,,206.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,269.47,
UREA BREATH TEST QUALITATIVE,4000012,CDM,301,RC,83013,HCPCS,Outpatient,,,191,95.50,,124.15,65,,99.32,Percent of Total Billed Charges,65% of Total Billed Charges,129.88,68,,103.904,Percent of Total Billed Charges,68% of Total Billed Charges,88.8,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,38.2,20,,30.56,Percent of Total Billed Charges,20% of Total Billed Charges,38.2,20,,30.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.2,20,,30.56,Percent of Total Billed Charges,20% of Total Billed Charges,38.2,20,,30.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.15,65,,99.32,Percent of Total Billed Charges,65% of Total Billed Charges,124.15,65,,99.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.5,50,,76.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.2,129.88,
STONE ANALYSIS,4000015,CDM,301,RC,82360,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,12.09,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,63.04,
STREP A RNA,4000016,CDM,300,RC,87651,HCPCS,Outpatient,,,54.19,27.10,,35.22,65,,28.176,Percent of Total Billed Charges,65% of Total Billed Charges,36.85,68,,29.48,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,20,,8.672,Percent of Total Billed Charges,20% of Total Billed Charges,10.84,20,,8.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,20,,8.672,Percent of Total Billed Charges,20% of Total Billed Charges,10.84,20,,8.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.22,65,,28.176,Percent of Total Billed Charges,65% of Total Billed Charges,35.22,65,,28.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.1,50,,21.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,36.85,
LIPID PANEL,4000017,CDM,301,RC,80061,HCPCS,Outpatient,,,168,84.00,,109.2,65,,87.36,Percent of Total Billed Charges,65% of Total Billed Charges,114.24,68,,91.392,Percent of Total Billed Charges,68% of Total Billed Charges,19.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,33.6,20,,26.88,Percent of Total Billed Charges,20% of Total Billed Charges,33.6,20,,26.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.6,20,,26.88,Percent of Total Billed Charges,20% of Total Billed Charges,33.6,20,,26.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.2,65,,87.36,Percent of Total Billed Charges,65% of Total Billed Charges,109.2,65,,87.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.01,114.24,
AMMONIA REF LAB,4000019,CDM,301,RC,82140,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,20.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,63.04,
OCCULT BLOOD - STOOL,4000023,CDM,301,RC,82270,HCPCS,Outpatient,,,67.98,33.99,,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,46.23,68,,36.984,Percent of Total Billed Charges,68% of Total Billed Charges,3.59,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,44.19,65,,35.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,50,,27.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.59,46.23,
OCCULT BLOOD - STOOL,4000024,CDM,301,RC,82272,HCPCS,Outpatient,,,22.66,11.33,,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,15.41,68,,12.328,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,15.41,
CK TOTAL,4000025,CDM,301,RC,82553,HCPCS,Outpatient,,,92,46.00,,59.8,65,,47.84,Percent of Total Billed Charges,65% of Total Billed Charges,62.56,68,,50.048,Percent of Total Billed Charges,68% of Total Billed Charges,12.86,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.4,20,,14.72,Percent of Total Billed Charges,20% of Total Billed Charges,18.4,20,,14.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,20,,14.72,Percent of Total Billed Charges,20% of Total Billed Charges,18.4,20,,14.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.8,65,,47.84,Percent of Total Billed Charges,65% of Total Billed Charges,59.8,65,,47.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.86,62.56,
HDL CHOLESTEROL,4000027,CDM,301,RC,83718,HCPCS,Outpatient,,,39.66,19.83,,25.78,65,,20.624,Percent of Total Billed Charges,65% of Total Billed Charges,26.97,68,,21.576,Percent of Total Billed Charges,68% of Total Billed Charges,11.62,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,7.93,20,,6.344,Percent of Total Billed Charges,20% of Total Billed Charges,7.93,20,,6.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.93,20,,6.344,Percent of Total Billed Charges,20% of Total Billed Charges,7.93,20,,6.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.78,65,,20.624,Percent of Total Billed Charges,65% of Total Billed Charges,25.78,65,,20.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.83,50,,15.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.93,26.97,
SERUM ACETONE,4000029,CDM,301,RC,82009,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,6.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,49.03,
AMYLASE,4000031,CDM,301,RC,82150,HCPCS,Outpatient,,,59,29.50,,38.35,65,,30.68,Percent of Total Billed Charges,65% of Total Billed Charges,40.12,68,,32.096,Percent of Total Billed Charges,68% of Total Billed Charges,9.2,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.35,65,,30.68,Percent of Total Billed Charges,65% of Total Billed Charges,38.35,65,,30.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.5,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,40.12,
BILIRUBIN DIRECT,4000033,CDM,301,RC,82248,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,6.94,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,56.03,
NEONATAL BILIRUBIN,4000034,CDM,301,RC,82248,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,6.94,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,56.03,
TOTAL BILIRUBIN,4000035,CDM,301,RC,82247,HCPCS,Outpatient,,,26.78,13.39,,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,18.21,68,,14.568,Percent of Total Billed Charges,68% of Total Billed Charges,6.94,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,50,,10.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,18.21,
BUN,4000037,CDM,301,RC,84520,HCPCS,Outpatient,,,75.75,37.88,,49.24,65,,39.392,Percent of Total Billed Charges,65% of Total Billed Charges,51.51,68,,41.208,Percent of Total Billed Charges,68% of Total Billed Charges,5.6,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.15,20,,12.12,Percent of Total Billed Charges,20% of Total Billed Charges,15.15,20,,12.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.15,20,,12.12,Percent of Total Billed Charges,20% of Total Billed Charges,15.15,20,,12.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.24,65,,39.392,Percent of Total Billed Charges,65% of Total Billed Charges,49.24,65,,39.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.88,50,,30.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,51.51,
CALCIUM,4000039,CDM,301,RC,82310,HCPCS,Outpatient,,,75,37.50,,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,7.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,51,
CO2,4000041,CDM,301,RC,82374,HCPCS,Outpatient,,,86,43.00,,55.9,65,,44.72,Percent of Total Billed Charges,65% of Total Billed Charges,58.48,68,,46.784,Percent of Total Billed Charges,68% of Total Billed Charges,6.94,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.2,20,,13.76,Percent of Total Billed Charges,20% of Total Billed Charges,17.2,20,,13.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,20,,13.76,Percent of Total Billed Charges,20% of Total Billed Charges,17.2,20,,13.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.9,65,,44.72,Percent of Total Billed Charges,65% of Total Billed Charges,55.9,65,,44.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43,50,,34.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,58.48,
CHLORIDE,4000043,CDM,301,RC,82435,HCPCS,Outpatient,,,65,32.50,,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,6.52,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.52,44.2,
CK TOTAL REF LAB,4000045,CDM,301,RC,82550,HCPCS,Outpatient,,,80,40.00,,52,65,,41.6,Percent of Total Billed Charges,65% of Total Billed Charges,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,9.25,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52,65,,41.6,Percent of Total Billed Charges,65% of Total Billed Charges,52,65,,41.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.25,54.4,
ELECTROLYTE PANEL-SERUM,4000049,CDM,301,RC,80051,HCPCS,Outpatient,,,47.59,23.80,,30.93,65,,24.744,Percent of Total Billed Charges,65% of Total Billed Charges,32.36,68,,25.888,Percent of Total Billed Charges,68% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.52,20,,7.616,Percent of Total Billed Charges,20% of Total Billed Charges,9.52,20,,7.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.52,20,,7.616,Percent of Total Billed Charges,20% of Total Billed Charges,9.52,20,,7.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.93,65,,24.744,Percent of Total Billed Charges,65% of Total Billed Charges,30.93,65,,24.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.8,50,,19.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.52,32.36,
ANTI DIURETIC HORMONE,4000050,CDM,301,RC,84588,HCPCS,Outpatient,,,173.04,86.52,,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,117.67,68,,94.136,Percent of Total Billed Charges,68% of Total Billed Charges,48.18,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.52,50,,69.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,117.67,
GLUCOSE POST-DOSE,4000051,CDM,301,RC,82950,HCPCS,Outpatient,,,82,41.00,,53.3,65,,42.64,Percent of Total Billed Charges,65% of Total Billed Charges,55.76,68,,44.608,Percent of Total Billed Charges,68% of Total Billed Charges,5.69,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.4,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,16.4,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.4,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,16.4,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.3,65,,42.64,Percent of Total Billed Charges,65% of Total Billed Charges,53.3,65,,42.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.69,55.76,
GLUCOSE,4000053,CDM,301,RC,82947,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,5.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.57,37.4,
GTT 2 HOUR CHARGE,4000055,CDM,301,RC,82951,HCPCS,Outpatient,,,75,37.50,,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,16.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,51,
GTT ADDITIONAL HOURS,4000057,CDM,301,RC,82952,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,4.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.77,37.4,
LDH,4000059,CDM,301,RC,83615,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,8.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.57,37.4,
DAILY LDH,4000060,CDM,301,RC,83615,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,8.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.57,37.4,
PHOSPHORUS,4000061,CDM,301,RC,84100,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,6.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.73,37.4,
POTASSIUM,4000063,CDM,301,RC,84132,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,6.52,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.52,37.4,
TOTAL PROTEIN,4000065,CDM,301,RC,84155,HCPCS,Outpatient,,,65,32.50,,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,5.2,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,44.2,
SALICYLATE,4000067,CDM,301,RC,80179,HCPCS,Outpatient,,,85,42.50,,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,57.8,
AST,4000069,CDM,301,RC,84450,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,7.33,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.33,37.4,
SODIUM,4000071,CDM,301,RC,84295,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,6.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.82,37.4,
URIC ACID,4000073,CDM,301,RC,84550,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,6.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,37.4,
ALBUMIN,4000075,CDM,301,RC,82040,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,5.67,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,37.4,
MAGNESIUM,4000077,CDM,301,RC,83735,HCPCS,Outpatient,,,149,74.50,,96.85,65,,77.48,Percent of Total Billed Charges,65% of Total Billed Charges,101.32,68,,81.056,Percent of Total Billed Charges,68% of Total Billed Charges,9.51,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,29.8,20,,23.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.8,20,,23.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.8,20,,23.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.8,20,,23.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.85,65,,77.48,Percent of Total Billed Charges,65% of Total Billed Charges,96.85,65,,77.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.5,50,,59.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.51,101.32,
ACID PHOSPHATASE,4000081,CDM,301,RC,84060,HCPCS,Outpatient,,,90.64,45.32,,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,61.64,68,,49.312,Percent of Total Billed Charges,68% of Total Billed Charges,10.48,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,50,,36.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.48,61.64,
ALK PHOS,4000083,CDM,301,RC,84075,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,7.34,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,37.4,
CATECHOLAMINES TOTAL URIN,4000085,CDM,301,RC,82382,HCPCS,Outpatient,,,169.95,84.98,,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,115.57,68,,92.456,Percent of Total Billed Charges,68% of Total Billed Charges,24.4,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.98,50,,67.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.4,115.57,
TOTAL CHOLESTEROL,4000087,CDM,301,RC,82465,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,4.69,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,37.4,
CORTISOL,4000089,CDM,301,RC,82533,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,23.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.75,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,58.13,
CREATINE KINASE ISOENZYMES-SERUM,4000091,CDM,301,RC,82552,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,19.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,63.04,
CREATININE CLEARANCE,4000093,CDM,301,RC,82575,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,13.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.41,49.03,
DIGOXIN LEVEL,4000097,CDM,301,RC,80162,HCPCS,Outpatient,,,73.65,36.83,,47.87,65,,38.296,Percent of Total Billed Charges,65% of Total Billed Charges,50.08,68,,40.064,Percent of Total Billed Charges,68% of Total Billed Charges,18.85,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.73,20,,11.784,Percent of Total Billed Charges,20% of Total Billed Charges,14.73,20,,11.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,20,,11.784,Percent of Total Billed Charges,20% of Total Billed Charges,14.73,20,,11.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.87,65,,38.296,Percent of Total Billed Charges,65% of Total Billed Charges,47.87,65,,38.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,50,,29.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,50.08,
PHENYTOIN LEVEL,4000099,CDM,301,RC,80185,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,18.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,49.03,
PROTEIN ELECTRPHRSIS SER,4000101,CDM,301,RC,84165,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,15.25,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.25,52.53,
FOLATE,4000103,CDM,301,RC,82746,HCPCS,Outpatient,,,75,37.50,,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,20.87,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,51,
HEAVY METALS SCREEN,4000105,CDM,301,RC,83015,HCPCS,Outpatient,,,241.02,120.51,,156.66,65,,125.328,Percent of Total Billed Charges,65% of Total Billed Charges,163.89,68,,131.112,Percent of Total Billed Charges,68% of Total Billed Charges,26.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,48.2,20,,38.56,Percent of Total Billed Charges,20% of Total Billed Charges,48.2,20,,38.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,20,,38.56,Percent of Total Billed Charges,20% of Total Billed Charges,48.2,20,,38.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.66,65,,125.328,Percent of Total Billed Charges,65% of Total Billed Charges,156.66,65,,125.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.51,50,,96.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.73,163.89,
IRON,4000109,CDM,301,RC,83540,HCPCS,Outpatient,,,33.99,17.00,,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,23.11,68,,18.488,Percent of Total Billed Charges,68% of Total Billed Charges,9.2,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,23.11,
IRON AND TIBC-SERUM PANEL,4000111,CDM,301,RC,83550,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,12.4,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,37.4,
MYSOLIN(PRIMIDONE),4000113,CDM,301,RC,80188,HCPCS,Outpatient,,,87.55,43.78,,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,59.53,68,,47.624,Percent of Total Billed Charges,68% of Total Billed Charges,23.27,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.78,50,,35.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,59.53,
ALT,4000115,CDM,301,RC,84460,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,7.52,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.52,37.4,
TRIGLYCERIDES,4000117,CDM,301,RC,84478,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,8.16,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.16,37.4,
THYROID STIMULATING HORMONE,4000119,CDM,301,RC,84443,HCPCS,Outpatient,,,149,74.50,,96.85,65,,77.48,Percent of Total Billed Charges,65% of Total Billed Charges,101.32,68,,81.056,Percent of Total Billed Charges,68% of Total Billed Charges,23.84,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,29.8,20,,23.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.8,20,,23.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.8,20,,23.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.8,20,,23.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.85,65,,77.48,Percent of Total Billed Charges,65% of Total Billed Charges,96.85,65,,77.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.5,50,,59.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.84,101.32,
T4 FREE (DIRECT) REF LAB,4000121,CDM,301,RC,84439,HCPCS,Outpatient,,,79.31,39.66,,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,53.93,68,,43.144,Percent of Total Billed Charges,68% of Total Billed Charges,12.8,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,50,,31.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,53.93,
VMA 24 HR UA,4000123,CDM,301,RC,84585,HCPCS,Outpatient,,,85,42.50,,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,57.8,
KETOSTEROIDS 17 24HR,4000125,CDM,301,RC,83582,HCPCS,Outpatient,,,85,42.50,,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,20.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,57.8,
HYDROCORTCOSTROID 17,4000127,CDM,301,RC,83491,HCPCS,Outpatient,,,110,55.00,,71.5,65,,57.2,Percent of Total Billed Charges,65% of Total Billed Charges,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,24.86,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.5,65,,57.2,Percent of Total Billed Charges,65% of Total Billed Charges,71.5,65,,57.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,74.8,
PHENOBARBITAL,4000131,CDM,301,RC,80184,HCPCS,Outpatient,,,75,37.50,,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,16.26,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,51,
ARSENIC QUANT,4000133,CDM,301,RC,82175,HCPCS,Outpatient,,,140,70.00,,91,65,,72.8,Percent of Total Billed Charges,65% of Total Billed Charges,95.2,68,,76.16,Percent of Total Billed Charges,68% of Total Billed Charges,26.93,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,28,20,,22.4,Percent of Total Billed Charges,20% of Total Billed Charges,28,20,,22.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,20,,22.4,Percent of Total Billed Charges,20% of Total Billed Charges,28,20,,22.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,65,,72.8,Percent of Total Billed Charges,65% of Total Billed Charges,91,65,,72.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.93,95.2,
LEAD,4000135,CDM,301,RC,83655,HCPCS,Outpatient,,,75,37.50,,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,17.18,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,51,
MERCURY,4000137,CDM,301,RC,83825,HCPCS,Outpatient,,,105,52.50,,68.25,65,,54.6,Percent of Total Billed Charges,65% of Total Billed Charges,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,23.07,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,21,20,,16.8,Percent of Total Billed Charges,20% of Total Billed Charges,21,20,,16.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,20,,16.8,Percent of Total Billed Charges,20% of Total Billed Charges,21,20,,16.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.25,65,,54.6,Percent of Total Billed Charges,65% of Total Billed Charges,68.25,65,,54.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,71.4,
HIAA 5,4000139,CDM,301,RC,83497,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,18.3,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
GGT,4000141,CDM,301,RC,82977,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,10.21,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.21,37.4,
PLASMA RENIN ACTIVITY,4000143,CDM,301,RC,84244,HCPCS,Outpatient,,,130.81,65.41,,85.03,65,,68.024,Percent of Total Billed Charges,65% of Total Billed Charges,88.95,68,,71.16,Percent of Total Billed Charges,68% of Total Billed Charges,31.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.03,65,,68.024,Percent of Total Billed Charges,65% of Total Billed Charges,85.03,65,,68.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.41,50,,52.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,88.95,
THEOPHYLLINE,4000145,CDM,301,RC,80198,HCPCS,Outpatient,,,85,42.50,,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,20.09,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,57.8,
OCCULT BLOOD GASTRIC,4000147,CDM,301,RC,82271,HCPCS,Outpatient,,,55,27.50,,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,4.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.61,37.4,
LITHIUM LEVEL,4000149,CDM,301,RC,80178,HCPCS,Outpatient,,,75,37.50,,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,9.38,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.38,51,
HEPATIC FUNCTION PANEL-SERUM,4000151,CDM,301,RC,80076,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,11.29,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.29,52.53,
PROLACTIN,4000153,CDM,301,RC,84146,HCPCS,Outpatient,,,105,52.50,,68.25,65,,54.6,Percent of Total Billed Charges,65% of Total Billed Charges,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,27.5,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,21,20,,16.8,Percent of Total Billed Charges,20% of Total Billed Charges,21,20,,16.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,20,,16.8,Percent of Total Billed Charges,20% of Total Billed Charges,21,20,,16.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.25,65,,54.6,Percent of Total Billed Charges,65% of Total Billed Charges,68.25,65,,54.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,71.4,
CARBAMAZEPINE LEVEL,4000155,CDM,301,RC,80156,HCPCS,Outpatient,,,76.22,38.11,,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,51.83,68,,41.464,Percent of Total Billed Charges,68% of Total Billed Charges,20.66,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,50,,30.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,51.83,
ACUTE HEPATITIS PANEL,4000157,CDM,301,RC,80074,HCPCS,Outpatient,,,225,112.50,,146.25,65,,117,Percent of Total Billed Charges,65% of Total Billed Charges,153,68,,122.4,Percent of Total Billed Charges,68% of Total Billed Charges,65.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,45,20,,36,Percent of Total Billed Charges,20% of Total Billed Charges,45,20,,36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,20,,36,Percent of Total Billed Charges,20% of Total Billed Charges,45,20,,36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.25,65,,117,Percent of Total Billed Charges,65% of Total Billed Charges,146.25,65,,117,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,153,
HEMOGLOBIN A1C,4000159,CDM,301,RC,83036,HCPCS,Outpatient,,,85,42.50,,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,13.78,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,17,20,,13.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,55.25,65,,44.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.78,57.8,
TOFRANIL,4000161,CDM,301,RC,80174,HCPCS,Outpatient,,,115.36,57.68,,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,78.44,68,,62.752,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,50,,46.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,78.44,
LIPASE,4000163,CDM,301,RC,83690,HCPCS,Outpatient,,,75,37.50,,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,9.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.77,51,
ALCOHOL,4000165,CDM,301,RC,82077,HCPCS,Outpatient,,,62.32,31.16,,40.51,65,,32.408,Percent of Total Billed Charges,65% of Total Billed Charges,42.38,68,,33.904,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.46,20,,9.968,Percent of Total Billed Charges,20% of Total Billed Charges,12.46,20,,9.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.46,20,,9.968,Percent of Total Billed Charges,20% of Total Billed Charges,12.46,20,,9.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.51,65,,32.408,Percent of Total Billed Charges,65% of Total Billed Charges,40.51,65,,32.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.16,50,,24.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.46,42.38,
DRUG SCREEN-URINE,4000169,CDM,301,RC,80305,HCPCS,Outpatient,,,296.64,148.32,,192.82,65,,154.256,Percent of Total Billed Charges,65% of Total Billed Charges,201.72,68,,161.376,Percent of Total Billed Charges,68% of Total Billed Charges,19.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,59.33,20,,47.464,Percent of Total Billed Charges,20% of Total Billed Charges,59.33,20,,47.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.33,20,,47.464,Percent of Total Billed Charges,20% of Total Billed Charges,59.33,20,,47.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.82,65,,154.256,Percent of Total Billed Charges,65% of Total Billed Charges,192.82,65,,154.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.32,50,,118.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.58,201.72,
FOLATE RBC,4000171,CDM,301,RC,82747,HCPCS,Outpatient,,,115,57.50,,74.75,65,,59.8,Percent of Total Billed Charges,65% of Total Billed Charges,78.2,68,,62.56,Percent of Total Billed Charges,68% of Total Billed Charges,4.25,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,23,20,,18.4,Percent of Total Billed Charges,20% of Total Billed Charges,23,20,,18.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,20,,18.4,Percent of Total Billed Charges,20% of Total Billed Charges,23,20,,18.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.75,65,,59.8,Percent of Total Billed Charges,65% of Total Billed Charges,74.75,65,,59.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.5,50,,46,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.25,78.2,
FERRITIN,4000173,CDM,301,RC,82728,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,19.33,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
FOLLICLE STIMULATG HORMONE(FSH)LEV-SERUM,4000175,CDM,301,RC,83001,HCPCS,Outpatient,,,90.64,45.32,,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,61.64,68,,49.312,Percent of Total Billed Charges,68% of Total Billed Charges,26.38,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,50,,36.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,61.64,
LUTEINIZING HORMONE (LH)-SERUM,4000177,CDM,301,RC,83002,HCPCS,Outpatient,,,89.61,44.81,,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,60.93,68,,48.744,Percent of Total Billed Charges,68% of Total Billed Charges,26.29,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.81,50,,35.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,60.93,
CYCLOSPORINE,4000179,CDM,301,RC,80158,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,24.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,50,,61.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.05,105.06,
AMIKACIN,4000181,CDM,301,RC,80150,HCPCS,Outpatient,,,97.85,48.93,,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,66.54,68,,53.232,Percent of Total Billed Charges,68% of Total Billed Charges,21.39,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.93,50,,39.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,66.54,
PROSTATE DIAGNOSTIC,4000183,CDM,301,RC,84153,HCPCS,Outpatient,,,83.43,41.72,,54.23,65,,43.384,Percent of Total Billed Charges,65% of Total Billed Charges,56.73,68,,45.384,Percent of Total Billed Charges,68% of Total Billed Charges,26.11,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.23,65,,43.384,Percent of Total Billed Charges,65% of Total Billed Charges,54.23,65,,43.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.72,50,,33.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,56.73,
QUINIDINE,4000185,CDM,301,RC,80194,HCPCS,Outpatient,,,89.61,44.81,,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,60.93,68,,48.744,Percent of Total Billed Charges,68% of Total Billed Charges,20.72,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.81,50,,35.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,60.93,
BASIC METABOLIC PANEL,4000187,CDM,301,RC,80048,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,11.7,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.7,52.53,
DAILY BMP,4000188,CDM,301,RC,80048,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,11.7,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.7,52.53,
GENTAMICIN TROUGH,4000189,CDM,301,RC,80170,HCPCS,Outpatient,,,75.19,37.60,,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,51.13,68,,40.904,Percent of Total Billed Charges,68% of Total Billed Charges,23.26,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.6,50,,30.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.04,51.13,
LACTATE DEHYDROGENASE(LDH)ISOENZYMES-SER,4000191,CDM,301,RC,83625,HCPCS,Outpatient,,,80.34,40.17,,52.22,65,,41.776,Percent of Total Billed Charges,65% of Total Billed Charges,54.63,68,,43.704,Percent of Total Billed Charges,68% of Total Billed Charges,18.16,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.07,20,,12.856,Percent of Total Billed Charges,20% of Total Billed Charges,16.07,20,,12.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,20,,12.856,Percent of Total Billed Charges,20% of Total Billed Charges,16.07,20,,12.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.22,65,,41.776,Percent of Total Billed Charges,65% of Total Billed Charges,52.22,65,,41.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,50,,32.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,54.63,
NORTRIPTYLINE,4000193,CDM,301,RC,80182,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.85,50,,78.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,133.08,
ZARONTIN,4000195,CDM,301,RC,80168,HCPCS,Outpatient,,,104.03,52.02,,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,70.74,68,,56.592,Percent of Total Billed Charges,68% of Total Billed Charges,23.19,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.02,50,,41.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,70.74,
C PEPTIDE,4000197,CDM,301,RC,84681,HCPCS,Outpatient,,,141.11,70.56,,91.72,65,,73.376,Percent of Total Billed Charges,65% of Total Billed Charges,95.95,68,,76.76,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.72,65,,73.376,Percent of Total Billed Charges,65% of Total Billed Charges,91.72,65,,73.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.56,50,,56.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.52,95.95,
VALPROIC ACID (DEPAKOTE),4000199,CDM,301,RC,80164,HCPCS,Outpatient,,,73.13,36.57,,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,49.73,68,,39.784,Percent of Total Billed Charges,68% of Total Billed Charges,19.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,50,,29.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,49.73,
ACETAMINOPHEN LEVEL,4000201,CDM,301,RC,80143,HCPCS,Outpatient,,,90.64,45.32,,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,61.64,68,,49.312,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,50,,36.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,61.64,
OSMOLALITY SERUM,4000203,CDM,301,RC,83930,HCPCS,Outpatient,,,60.77,30.39,,39.5,65,,31.6,Percent of Total Billed Charges,65% of Total Billed Charges,41.32,68,,33.056,Percent of Total Billed Charges,68% of Total Billed Charges,9.38,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.5,65,,31.6,Percent of Total Billed Charges,65% of Total Billed Charges,39.5,65,,31.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.39,50,,24.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.38,41.32,
CALCIUM 24 HR UA,4000205,CDM,301,RC,82340,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,8.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.57,36.42,
OXALATE 24 HR UA,4000207,CDM,301,RC,83945,HCPCS,Outpatient,,,88.58,44.29,,57.58,65,,46.064,Percent of Total Billed Charges,65% of Total Billed Charges,60.23,68,,48.184,Percent of Total Billed Charges,68% of Total Billed Charges,18.28,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.72,20,,14.176,Percent of Total Billed Charges,20% of Total Billed Charges,17.72,20,,14.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.72,20,,14.176,Percent of Total Billed Charges,20% of Total Billed Charges,17.72,20,,14.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.58,65,,46.064,Percent of Total Billed Charges,65% of Total Billed Charges,57.58,65,,46.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.29,50,,35.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.72,60.23,
URIC ACID 24HR URINE,4000209,CDM,301,RC,84560,HCPCS,Outpatient,,,51.5,25.75,,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,68,,28.016,Percent of Total Billed Charges,68% of Total Billed Charges,6.74,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,50,,20.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.74,35.02,
CITRATE 24 HOUR UA,4000211,CDM,301,RC,82507,HCPCS,Outpatient,,,209.09,104.55,,135.91,65,,108.728,Percent of Total Billed Charges,65% of Total Billed Charges,142.18,68,,113.744,Percent of Total Billed Charges,68% of Total Billed Charges,39.47,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,41.82,20,,33.456,Percent of Total Billed Charges,20% of Total Billed Charges,41.82,20,,33.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.82,20,,33.456,Percent of Total Billed Charges,20% of Total Billed Charges,41.82,20,,33.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.91,65,,108.728,Percent of Total Billed Charges,65% of Total Billed Charges,135.91,65,,108.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.55,50,,83.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.47,142.18,
CERULOPLASM,4000213,CDM,301,RC,82390,HCPCS,Outpatient,,,71.07,35.54,,46.2,65,,36.96,Percent of Total Billed Charges,65% of Total Billed Charges,48.33,68,,38.664,Percent of Total Billed Charges,68% of Total Billed Charges,15.25,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.21,20,,11.368,Percent of Total Billed Charges,20% of Total Billed Charges,14.21,20,,11.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.21,20,,11.368,Percent of Total Billed Charges,20% of Total Billed Charges,14.21,20,,11.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.2,65,,36.96,Percent of Total Billed Charges,65% of Total Billed Charges,46.2,65,,36.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.54,50,,28.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.21,48.33,
DOXEPIN,4000215,CDM,301,RC,80166,HCPCS,Outpatient,,,103,51.50,,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,70.04,68,,56.032,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,70.04,
TOX ROUTN PRIVATE PAY CASH CONTRACT,4000217,CDM,301,RC,80305,HCPCS,Outpatient,,,45,22.50,,29.25,65,,23.4,Percent of Total Billed Charges,65% of Total Billed Charges,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,19.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.25,65,,23.4,Percent of Total Billed Charges,65% of Total Billed Charges,29.25,65,,23.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,30.6,
ESTROGEN TOTAL,4000221,CDM,301,RC,82672,HCPCS,Outpatient,,,123.6,61.80,,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,84.05,68,,67.24,Percent of Total Billed Charges,68% of Total Billed Charges,30.78,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,50,,49.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,84.05,
PROGESTERONE,4000223,CDM,301,RC,84144,HCPCS,Outpatient,,,83.43,41.72,,54.23,65,,43.384,Percent of Total Billed Charges,65% of Total Billed Charges,56.73,68,,45.384,Percent of Total Billed Charges,68% of Total Billed Charges,29.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,16.69,20,,13.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.23,65,,43.384,Percent of Total Billed Charges,65% of Total Billed Charges,54.23,65,,43.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.72,50,,33.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.69,56.73,
ZINC-SERUM,4000225,CDM,301,RC,84630,HCPCS,Outpatient,,,78.28,39.14,,50.88,65,,40.704,Percent of Total Billed Charges,65% of Total Billed Charges,53.23,68,,42.584,Percent of Total Billed Charges,68% of Total Billed Charges,16.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.66,20,,12.528,Percent of Total Billed Charges,20% of Total Billed Charges,15.66,20,,12.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.66,20,,12.528,Percent of Total Billed Charges,20% of Total Billed Charges,15.66,20,,12.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.88,65,,40.704,Percent of Total Billed Charges,65% of Total Billed Charges,50.88,65,,40.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,50,,31.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.66,53.23,
.C DIFF ANTIGEN,4000226,CDM,306,RC,87449,HCPCS,Outpatient,,,74.16,37.08,,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,50.43,68,,40.344,Percent of Total Billed Charges,68% of Total Billed Charges,16.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,50,,29.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,50.43,
B-6,4000227,CDM,301,RC,84207,HCPCS,Outpatient,,,236.9,118.45,,153.99,65,,123.192,Percent of Total Billed Charges,65% of Total Billed Charges,161.09,68,,128.872,Percent of Total Billed Charges,68% of Total Billed Charges,25.72,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,47.38,20,,37.904,Percent of Total Billed Charges,20% of Total Billed Charges,47.38,20,,37.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.38,20,,37.904,Percent of Total Billed Charges,20% of Total Billed Charges,47.38,20,,37.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.99,65,,123.192,Percent of Total Billed Charges,65% of Total Billed Charges,153.99,65,,123.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.45,50,,94.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.72,161.09,
.C DIFF TOXIN,4000228,CDM,306,RC,87324,HCPCS,Outpatient,,,74.16,37.08,,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,50.43,68,,40.344,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,50,,29.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,50.43,
DHEA SULFATE,4000229,CDM,301,RC,82627,HCPCS,Outpatient,,,149.35,74.68,,97.08,65,,77.664,Percent of Total Billed Charges,65% of Total Billed Charges,101.56,68,,81.248,Percent of Total Billed Charges,68% of Total Billed Charges,31.56,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,29.87,20,,23.896,Percent of Total Billed Charges,20% of Total Billed Charges,29.87,20,,23.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.87,20,,23.896,Percent of Total Billed Charges,20% of Total Billed Charges,29.87,20,,23.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.08,65,,77.664,Percent of Total Billed Charges,65% of Total Billed Charges,97.08,65,,77.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.68,50,,59.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.87,101.56,
FLUOXETINE,4000231,CDM,301,RC,80299,HCPCS,Outpatient,,,101.97,50.99,,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,69.34,68,,55.472,Percent of Total Billed Charges,68% of Total Billed Charges,19.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,50,,40.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.43,69.34,
NEURONTIN,4000233,CDM,301,RC,80171,HCPCS,Outpatient,,,113.3,56.65,,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,77.04,68,,61.632,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.65,50,,45.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,77.04,
ALUMINUM,4000235,CDM,301,RC,82108,HCPCS,Outpatient,,,94.76,47.38,,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,64.44,68,,51.552,Percent of Total Billed Charges,68% of Total Billed Charges,36.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.38,50,,37.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,64.44,
TRANSFERRIN-SERUM,4000237,CDM,301,RC,84466,HCPCS,Outpatient,,,73.13,36.57,,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,49.73,68,,39.784,Percent of Total Billed Charges,68% of Total Billed Charges,18.13,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,50,,29.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,49.73,
AMIODARONE,4000239,CDM,301,RC,80299,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,19.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,50,,61.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.43,105.06,
QUANTIFERON TB GOLD TEST,4000240,CDM,302,RC,86480,HCPCS,Outpatient,,,123.6,61.80,,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,84.05,68,,67.24,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,50,,49.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,84.05,
ESTRADIOL,4000241,CDM,301,RC,82670,HCPCS,Outpatient,,,125.66,62.83,,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,85.45,68,,68.36,Percent of Total Billed Charges,68% of Total Billed Charges,39.66,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,50,,50.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.13,85.45,
TESTOSTERONE TOTAL,4000243,CDM,301,RC,84403,HCPCS,Outpatient,,,118.45,59.23,,76.99,65,,61.592,Percent of Total Billed Charges,65% of Total Billed Charges,80.55,68,,64.44,Percent of Total Billed Charges,68% of Total Billed Charges,36.64,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,23.69,20,,18.952,Percent of Total Billed Charges,20% of Total Billed Charges,23.69,20,,18.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.69,20,,18.952,Percent of Total Billed Charges,20% of Total Billed Charges,23.69,20,,18.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.99,65,,61.592,Percent of Total Billed Charges,65% of Total Billed Charges,76.99,65,,61.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.23,50,,47.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.69,80.55,
URINE 24 HR CALCIUM,4000245,CDM,301,RC,82340,HCPCS,Outpatient,,,51.5,25.75,,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,68,,28.016,Percent of Total Billed Charges,68% of Total Billed Charges,8.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,50,,20.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.57,35.02,
METANEPHRINES,4000247,CDM,301,RC,83835,HCPCS,Outpatient,,,89.61,44.81,,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,60.93,68,,48.744,Percent of Total Billed Charges,68% of Total Billed Charges,24.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.81,50,,35.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,60.93,
HCG QUANTITATIVE (In House),4000249,CDM,301,RC,84702,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,21.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.75,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,58.13,
IMMUNOGLOBULINS A G M,4000251,CDM,301,RC,82784,HCPCS,Outpatient,,,59.74,29.87,,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,40.62,68,,32.496,Percent of Total Billed Charges,68% of Total Billed Charges,13.2,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.87,50,,23.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,40.62,
HCG QUANTITATIVE -QUEST,4000252,CDM,301,RC,84702,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,21.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.75,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,58.13,
IGE,4000253,CDM,301,RC,82785,HCPCS,Outpatient,,,78.28,39.14,,50.88,65,,40.704,Percent of Total Billed Charges,65% of Total Billed Charges,53.23,68,,42.584,Percent of Total Billed Charges,68% of Total Billed Charges,23.38,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.66,20,,12.528,Percent of Total Billed Charges,20% of Total Billed Charges,15.66,20,,12.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.66,20,,12.528,Percent of Total Billed Charges,20% of Total Billed Charges,15.66,20,,12.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.88,65,,40.704,Percent of Total Billed Charges,65% of Total Billed Charges,50.88,65,,40.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,50,,31.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.66,53.23,
URINE CORTISOL 24 HR,4000257,CDM,301,RC,82533,HCPCS,Outpatient,,,107.12,53.56,,69.63,65,,55.704,Percent of Total Billed Charges,65% of Total Billed Charges,72.84,68,,58.272,Percent of Total Billed Charges,68% of Total Billed Charges,23.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,21.42,20,,17.136,Percent of Total Billed Charges,20% of Total Billed Charges,21.42,20,,17.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.42,20,,17.136,Percent of Total Billed Charges,20% of Total Billed Charges,21.42,20,,17.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.63,65,,55.704,Percent of Total Billed Charges,65% of Total Billed Charges,69.63,65,,55.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,50,,42.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.42,72.84,
TOBRAMYCIN PEAK,4000259,CDM,301,RC,80200,HCPCS,Outpatient,,,87.55,43.78,,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,59.53,68,,47.624,Percent of Total Billed Charges,68% of Total Billed Charges,22.88,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.78,50,,35.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,59.53,
TOBRAMYCIN,4000260,CDM,301,RC,80200,HCPCS,Outpatient,,,87.55,43.78,,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,59.53,68,,47.624,Percent of Total Billed Charges,68% of Total Billed Charges,22.88,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.78,50,,35.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,59.53,
TOBRAMYCIN TROUGH,4000262,CDM,301,RC,80200,HCPCS,Outpatient,,,87.55,43.78,,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,59.53,68,,47.624,Percent of Total Billed Charges,68% of Total Billed Charges,22.88,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.78,50,,35.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,59.53,
VANCOMYCIN LEVEL,4000263,CDM,301,RC,80202,HCPCS,Outpatient,,,133.9,66.95,,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,68,,72.84,Percent of Total Billed Charges,68% of Total Billed Charges,19.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,50,,53.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.23,91.05,
DESIPRAMINE,4000265,CDM,301,RC,80160,HCPCS,Outpatient,,,103,51.50,,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,70.04,68,,56.032,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,70.04,
ELECTROPHORESIS IMMU,4000267,CDM,302,RC,86334,HCPCS,Outpatient,,,43.26,21.63,,28.12,65,,22.496,Percent of Total Billed Charges,65% of Total Billed Charges,29.42,68,,23.536,Percent of Total Billed Charges,68% of Total Billed Charges,31.71,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.65,20,,6.92,Percent of Total Billed Charges,20% of Total Billed Charges,8.65,20,,6.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,20,,6.92,Percent of Total Billed Charges,20% of Total Billed Charges,8.65,20,,6.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.12,65,,22.496,Percent of Total Billed Charges,65% of Total Billed Charges,28.12,65,,22.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,50,,17.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,31.71,
DRUG SCREEN CONFIRM,4000275,CDM,301,RC,80305,HCPCS,Outpatient,,,63.86,31.93,,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,43.42,68,,34.736,Percent of Total Billed Charges,68% of Total Billed Charges,19.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.93,50,,25.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,43.42,
ANGIOTENSIN CON ENZM,4000279,CDM,301,RC,82164,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,20.72,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
OSMOLALITY OF URINE,4000283,CDM,301,RC,83935,HCPCS,Outpatient,,,59.74,29.87,,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,40.62,68,,32.496,Percent of Total Billed Charges,68% of Total Billed Charges,9.67,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.87,50,,23.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.67,40.62,
VASOINTESTINAL PEPTI,4000287,CDM,301,RC,84586,HCPCS,Outpatient,,,164.8,82.40,,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,112.06,68,,89.648,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.4,50,,65.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.52,112.06,
ALDOLASE-SERUM,4000291,CDM,301,RC,82085,HCPCS,Outpatient,,,70.04,35.02,,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,47.63,68,,38.104,Percent of Total Billed Charges,68% of Total Billed Charges,13.78,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,50,,28.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.78,47.63,
AFP-TRIPLE TEST,4000293,CDM,301,RC,82107,HCPCS,Outpatient,,,175.62,87.81,,114.15,65,,91.32,Percent of Total Billed Charges,65% of Total Billed Charges,119.42,68,,95.536,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.12,20,,28.096,Percent of Total Billed Charges,20% of Total Billed Charges,35.12,20,,28.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.12,20,,28.096,Percent of Total Billed Charges,20% of Total Billed Charges,35.12,20,,28.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.15,65,,91.32,Percent of Total Billed Charges,65% of Total Billed Charges,114.15,65,,91.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.81,50,,70.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.12,119.42,
TIBC,4000295,CDM,301,RC,83550,HCPCS,Outpatient,,,51.5,25.75,,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,68,,28.016,Percent of Total Billed Charges,68% of Total Billed Charges,12.4,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,50,,20.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,35.02,
HAPTOGLOBIN,4000297,CDM,301,RC,83010,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,17.85,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
ERYTHROPOIETIN,4000299,CDM,301,RC,82668,HCPCS,Outpatient,,,141.11,70.56,,91.72,65,,73.376,Percent of Total Billed Charges,65% of Total Billed Charges,95.95,68,,76.76,Percent of Total Billed Charges,68% of Total Billed Charges,26.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,28.22,20,,22.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.72,65,,73.376,Percent of Total Billed Charges,65% of Total Billed Charges,91.72,65,,73.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.56,50,,56.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.68,95.95,
T4 TOTAL,4000301,CDM,301,RC,84439,HCPCS,Outpatient,,,91.67,45.84,,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,62.34,68,,49.872,Percent of Total Billed Charges,68% of Total Billed Charges,12.8,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.84,50,,36.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,62.34,
ALDOSTERONE-SERUM,4000303,CDM,301,RC,82088,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,57.84,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.85,50,,78.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,133.08,
URINE AMYLASE,4000305,CDM,301,RC,82150,HCPCS,Outpatient,,,52.53,26.27,,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,35.72,68,,28.576,Percent of Total Billed Charges,68% of Total Billed Charges,9.2,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.27,50,,21.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,35.72,
VITAMIN B12,4000307,CDM,301,RC,82607,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,21.39,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,49.03,
URINE PROTEIN 24HR,4000309,CDM,301,RC,84156,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,36.42,
RANDOM SODIUM URNE W/CREAT,4000311,CDM,301,RC,84300,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,6.9,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,36.42,
CREAT UR-MCNC,4000313,CDM,301,RC,82570,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,7.34,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,36.42,
POTASSIUM URINE W/CREAT 24 HR,4000315,CDM,301,RC,84133,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,6.1,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.1,36.42,
ORGANIC ACIDS,4000317,CDM,301,RC,83918,HCPCS,Outpatient,,,111.24,55.62,,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,75.64,68,,60.512,Percent of Total Billed Charges,68% of Total Billed Charges,20.96,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.62,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.96,75.64,
AMINO ACIDS QUANTITY,4000319,CDM,301,RC,82131,HCPCS,Outpatient,,,74.16,37.08,,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,50.43,68,,40.344,Percent of Total Billed Charges,68% of Total Billed Charges,6.69,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,50,,29.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.69,50.43,
COMPREHENSIVE METABOLIC PANEL,4000321,CDM,301,RC,80053,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,14.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,50,,61.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,105.06,
DAILY CMP,4000322,CDM,301,RC,80053,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,14.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,50,,61.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,105.06,
COMPREHENSIVE METABOLIC PANEL PICCOLO,4000323,CDM,301,RC,80053,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,14.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,50,,61.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,105.06,
PSA FREE,4000325,CDM,301,RC,84154,HCPCS,Outpatient,,,99.91,49.96,,64.94,65,,51.952,Percent of Total Billed Charges,65% of Total Billed Charges,67.94,68,,54.352,Percent of Total Billed Charges,68% of Total Billed Charges,25.42,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.98,20,,15.984,Percent of Total Billed Charges,20% of Total Billed Charges,19.98,20,,15.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,20,,15.984,Percent of Total Billed Charges,20% of Total Billed Charges,19.98,20,,15.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.94,65,,51.952,Percent of Total Billed Charges,65% of Total Billed Charges,64.94,65,,51.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.96,50,,39.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,67.94,
THYROXINE BINDING GL,4000327,CDM,301,RC,84442,HCPCS,Outpatient,,,103,51.50,,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,70.04,68,,56.032,Percent of Total Billed Charges,68% of Total Billed Charges,20.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,70.04,
THYROID STIMULAT IG,4000329,CDM,301,RC,84445,HCPCS,Outpatient,,,333.72,166.86,,216.92,65,,173.536,Percent of Total Billed Charges,65% of Total Billed Charges,226.93,68,,181.544,Percent of Total Billed Charges,68% of Total Billed Charges,24.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,66.74,20,,53.392,Percent of Total Billed Charges,20% of Total Billed Charges,66.74,20,,53.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.74,20,,53.392,Percent of Total Billed Charges,20% of Total Billed Charges,66.74,20,,53.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.92,65,,173.536,Percent of Total Billed Charges,65% of Total Billed Charges,216.92,65,,173.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.86,50,,133.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.05,226.93,
THIAMINE-VIT B1,4000331,CDM,301,RC,84425,HCPCS,Outpatient,,,175.1,87.55,,113.82,65,,91.056,Percent of Total Billed Charges,65% of Total Billed Charges,119.07,68,,95.256,Percent of Total Billed Charges,68% of Total Billed Charges,12.09,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,35.02,20,,28.016,Percent of Total Billed Charges,20% of Total Billed Charges,35.02,20,,28.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,20,,28.016,Percent of Total Billed Charges,20% of Total Billed Charges,35.02,20,,28.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.82,65,,91.056,Percent of Total Billed Charges,65% of Total Billed Charges,113.82,65,,91.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,119.07,
MICROALBUMIN URINE,4000333,CDM,301,RC,82043,HCPCS,Outpatient,,,87.55,43.78,,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,59.53,68,,47.624,Percent of Total Billed Charges,68% of Total Billed Charges,2.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.78,50,,35.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,59.53,
URINE MYOGLOBIN,4000336,CDM,301,RC,83874,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,18.32,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,28.02,
INSULIN TOLERANCE,4000339,CDM,301,RC,83525,HCPCS,Outpatient,,,200.85,100.43,,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,136.58,68,,109.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,50,,80.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.23,136.58,
AMITRIPTYLINE,4000341,CDM,301,RC,80152,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,63.04,
ANTIDIURETIC HORMONE,4000343,CDM,301,RC,84588,HCPCS,Outpatient,,,169.95,84.98,,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,115.57,68,,92.456,Percent of Total Billed Charges,68% of Total Billed Charges,48.18,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.98,50,,67.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,115.57,
TOX COLLECT ONLY CONTRACT INVOICE,4000345,CDM,301,RC,99001,HCPCS,Outpatient,,,20,10.00,,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,3,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,13.6,
LAMOTRIGINE SERPL-MCNC,4000347,CDM,301,RC,80299,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,19.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.75,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,58.13,
NICOTINE LEVEL,4000349,CDM,301,RC,83887,HCPCS,Outpatient,,,104.03,52.02,,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,70.74,68,,56.592,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.02,50,,41.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,70.74,
HSV 1&2 IgG,4000350,CDM,301,RC,84439,HCPCS,Outpatient,,,91.67,45.84,,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,62.34,68,,49.872,Percent of Total Billed Charges,68% of Total Billed Charges,12.8,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.84,50,,36.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,62.34,
CARBON MONIXIDE,4000353,CDM,301,RC,82375,HCPCS,Outpatient,,,79.05,39.53,,51.38,65,,41.104,Percent of Total Billed Charges,65% of Total Billed Charges,53.75,68,,43,Percent of Total Billed Charges,68% of Total Billed Charges,17.5,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.81,20,,12.648,Percent of Total Billed Charges,20% of Total Billed Charges,15.81,20,,12.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.81,20,,12.648,Percent of Total Billed Charges,20% of Total Billed Charges,15.81,20,,12.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.38,65,,41.104,Percent of Total Billed Charges,65% of Total Billed Charges,51.38,65,,41.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.53,50,,31.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.81,53.75,
PROCAINAMIDE & NAPA,4000355,CDM,301,RC,80190,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,23.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
CALCIUM IONIZED,4000357,CDM,301,RC,82330,HCPCS,Outpatient,,,69.01,34.51,,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,46.93,68,,37.544,Percent of Total Billed Charges,68% of Total Billed Charges,19.4,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.51,50,,27.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.8,46.93,
APOLIPOPROTEIN EGENO,4000359,CDM,301,RC,82172,HCPCS,Outpatient,,,302.82,151.41,,196.83,65,,157.464,Percent of Total Billed Charges,65% of Total Billed Charges,205.92,68,,164.736,Percent of Total Billed Charges,68% of Total Billed Charges,19.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,60.56,20,,48.448,Percent of Total Billed Charges,20% of Total Billed Charges,60.56,20,,48.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.56,20,,48.448,Percent of Total Billed Charges,20% of Total Billed Charges,60.56,20,,48.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.83,65,,157.464,Percent of Total Billed Charges,65% of Total Billed Charges,196.83,65,,157.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.41,50,,121.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.58,205.92,
SILICONE LEVEL,4000361,CDM,301,RC,84285,HCPCS,Outpatient,,,109.18,54.59,,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,74.24,68,,59.392,Percent of Total Billed Charges,68% of Total Billed Charges,33.42,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.59,50,,43.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,74.24,
TROPONIN-I,4000363,CDM,301,RC,84484,HCPCS,Outpatient,,,66.95,33.48,,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,68,,36.424,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,50,,26.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,45.53,
RENAL FUNCTION PANEL-SERUM,4000365,CDM,301,RC,80069,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,50,,61.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,105.06,
ACTH,4000367,CDM,301,RC,82024,HCPCS,Outpatient,,,193.64,96.82,,125.87,65,,100.696,Percent of Total Billed Charges,65% of Total Billed Charges,131.68,68,,105.344,Percent of Total Billed Charges,68% of Total Billed Charges,54.83,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,38.73,20,,30.984,Percent of Total Billed Charges,20% of Total Billed Charges,38.73,20,,30.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.73,20,,30.984,Percent of Total Billed Charges,20% of Total Billed Charges,38.73,20,,30.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.87,65,,100.696,Percent of Total Billed Charges,65% of Total Billed Charges,125.87,65,,100.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.82,50,,77.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.73,131.68,
DEMEROL,4000371,CDM,301,RC,83925,HCPCS,Outpatient,,,74.16,37.08,,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,50.43,68,,40.344,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,14.83,20,,11.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,48.2,65,,38.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,50,,29.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,50.43,
ISO/EXA NOCLEICACID,4000373,CDM,301,RC,,,Outpatient,,,51.5,25.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,35,,14.424,Percent of Total Billed Charges,35% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,33.48,
T PROTEIN CSF,4000381,CDM,301,RC,84157,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
GLUCOSE BODY FLUID,4000383,CDM,301,RC,82945,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
HALDOL ASSAY,4000385,CDM,301,RC,80173,HCPCS,Outpatient,,,55.62,27.81,,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,37.82,68,,30.256,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.81,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,37.82,
T3 TOTAL-SERUM,4000387,CDM,301,RC,84480,HCPCS,Outpatient,,,108.15,54.08,,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,73.54,68,,58.832,Percent of Total Billed Charges,68% of Total Billed Charges,20.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.08,50,,43.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.12,73.54,
T3 UPTAKE-SERUM,4000389,CDM,301,RC,84479,HCPCS,Outpatient,,,44.29,22.15,,28.79,65,,23.032,Percent of Total Billed Charges,65% of Total Billed Charges,30.12,68,,24.096,Percent of Total Billed Charges,68% of Total Billed Charges,9.19,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.86,20,,7.088,Percent of Total Billed Charges,20% of Total Billed Charges,8.86,20,,7.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.86,20,,7.088,Percent of Total Billed Charges,20% of Total Billed Charges,8.86,20,,7.088,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.79,65,,23.032,Percent of Total Billed Charges,65% of Total Billed Charges,28.79,65,,23.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.15,50,,17.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.86,30.12,
T3 FREE-SERUM,4000391,CDM,301,RC,84481,HCPCS,Outpatient,,,219.39,109.70,,142.6,65,,114.08,Percent of Total Billed Charges,65% of Total Billed Charges,149.19,68,,119.352,Percent of Total Billed Charges,68% of Total Billed Charges,21.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,43.88,20,,35.104,Percent of Total Billed Charges,20% of Total Billed Charges,43.88,20,,35.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.88,20,,35.104,Percent of Total Billed Charges,20% of Total Billed Charges,43.88,20,,35.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.6,65,,114.08,Percent of Total Billed Charges,65% of Total Billed Charges,142.6,65,,114.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.7,50,,87.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.73,149.19,
URINE CHLORIDE,4000393,CDM,301,RC,82436,HCPCS,Outpatient,,,38.11,19.06,,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,25.91,68,,20.728,Percent of Total Billed Charges,68% of Total Billed Charges,4.5,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.06,50,,15.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,25.91,
TRILIPTEL,4000415,CDM,301,RC,82491,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,49.03,
TACROLIMUS (FK506),4000419,CDM,301,RC,80197,HCPCS,Outpatient,,,175.1,87.55,,113.82,65,,91.056,Percent of Total Billed Charges,65% of Total Billed Charges,119.07,68,,95.256,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,20,,28.016,Percent of Total Billed Charges,20% of Total Billed Charges,35.02,20,,28.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,20,,28.016,Percent of Total Billed Charges,20% of Total Billed Charges,35.02,20,,28.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.82,65,,91.056,Percent of Total Billed Charges,65% of Total Billed Charges,113.82,65,,91.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,119.07,
PHENYLALANINE,4000421,CDM,301,RC,84030,HCPCS,Outpatient,,,127.98,63.99,,83.19,65,,66.552,Percent of Total Billed Charges,65% of Total Billed Charges,87.03,68,,69.624,Percent of Total Billed Charges,68% of Total Billed Charges,7.81,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,25.6,20,,20.48,Percent of Total Billed Charges,20% of Total Billed Charges,25.6,20,,20.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.6,20,,20.48,Percent of Total Billed Charges,20% of Total Billed Charges,25.6,20,,20.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.19,65,,66.552,Percent of Total Billed Charges,65% of Total Billed Charges,83.19,65,,66.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.99,50,,51.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.81,87.03,
FECAL FAT QUANT,4000423,CDM,301,RC,82710,HCPCS,Outpatient,,,61.33,30.67,,39.86,65,,31.888,Percent of Total Billed Charges,65% of Total Billed Charges,41.7,68,,33.36,Percent of Total Billed Charges,68% of Total Billed Charges,21.88,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.27,20,,9.816,Percent of Total Billed Charges,20% of Total Billed Charges,12.27,20,,9.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.27,20,,9.816,Percent of Total Billed Charges,20% of Total Billed Charges,12.27,20,,9.816,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.86,65,,31.888,Percent of Total Billed Charges,65% of Total Billed Charges,39.86,65,,31.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.67,50,,24.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.27,41.7,
TESTOSTERONE (FREE),4000429,CDM,301,RC,84402,HCPCS,Outpatient,,,185.4,92.70,,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,126.07,68,,100.856,Percent of Total Billed Charges,68% of Total Billed Charges,36.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.7,50,,74.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.14,126.07,
TESTOSTERONE FREE AND TOTAL,4000430,CDM,301,RC,84402,HCPCS,Outpatient,,,185.4,92.70,,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,126.07,68,,100.856,Percent of Total Billed Charges,68% of Total Billed Charges,36.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.7,50,,74.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.14,126.07,
SEX BINDING HORMONE,4000431,CDM,301,RC,84270,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,11.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,28.02,
ALKPHOS ISOENZYMES,4000433,CDM,301,RC,84080,HCPCS,Outpatient,,,31.52,15.76,,20.49,65,,16.392,Percent of Total Billed Charges,65% of Total Billed Charges,21.43,68,,17.144,Percent of Total Billed Charges,68% of Total Billed Charges,20.99,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,6.3,20,,5.04,Percent of Total Billed Charges,20% of Total Billed Charges,6.3,20,,5.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.3,20,,5.04,Percent of Total Billed Charges,20% of Total Billed Charges,6.3,20,,5.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.49,65,,16.392,Percent of Total Billed Charges,65% of Total Billed Charges,20.49,65,,16.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.76,50,,12.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.3,21.43,
TOPIRAMATE,4000435,CDM,301,RC,80201,HCPCS,Outpatient,,,185.4,92.70,,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,126.07,68,,100.856,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.7,50,,74.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,126.07,
CRYOGLOBULIN,4000447,CDM,301,RC,82595,HCPCS,Outpatient,,,160.68,80.34,,104.44,65,,83.552,Percent of Total Billed Charges,65% of Total Billed Charges,109.26,68,,87.408,Percent of Total Billed Charges,68% of Total Billed Charges,9.19,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,32.14,20,,25.712,Percent of Total Billed Charges,20% of Total Billed Charges,32.14,20,,25.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.14,20,,25.712,Percent of Total Billed Charges,20% of Total Billed Charges,32.14,20,,25.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.44,65,,83.552,Percent of Total Billed Charges,65% of Total Billed Charges,104.44,65,,83.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.34,50,,64.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.19,109.26,
SPECIFIC GRAVITY FLD,4000449,CDM,301,RC,84315,HCPCS,Outpatient,,,5.71,2.86,,3.71,65,,2.968,Percent of Total Billed Charges,65% of Total Billed Charges,3.88,68,,3.104,Percent of Total Billed Charges,68% of Total Billed Charges,3.56,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,1.14,20,,0.912,Percent of Total Billed Charges,20% of Total Billed Charges,1.14,20,,0.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,20,,0.912,Percent of Total Billed Charges,20% of Total Billed Charges,1.14,20,,0.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,65,,2.968,Percent of Total Billed Charges,65% of Total Billed Charges,3.71,65,,2.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.86,50,,2.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,3.88,
TRIAGE BNP,4000451,CDM,301,RC,83880,HCPCS,Outpatient,,,180.25,90.13,,117.16,65,,93.728,Percent of Total Billed Charges,65% of Total Billed Charges,122.57,68,,98.056,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,20,,28.84,Percent of Total Billed Charges,20% of Total Billed Charges,36.05,20,,28.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,20,,28.84,Percent of Total Billed Charges,20% of Total Billed Charges,36.05,20,,28.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.16,65,,93.728,Percent of Total Billed Charges,65% of Total Billed Charges,117.16,65,,93.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.13,50,,72.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,122.57,
BNP SEND OUT REF LAB,4000452,CDM,301,RC,83880,HCPCS,Outpatient,,,245.14,122.57,,159.34,65,,127.472,Percent of Total Billed Charges,65% of Total Billed Charges,166.7,68,,133.36,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.03,20,,39.224,Percent of Total Billed Charges,20% of Total Billed Charges,49.03,20,,39.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.03,20,,39.224,Percent of Total Billed Charges,20% of Total Billed Charges,49.03,20,,39.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.34,65,,127.472,Percent of Total Billed Charges,65% of Total Billed Charges,159.34,65,,127.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.57,50,,98.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.03,166.7,
PARVOVIRUS B19 HUMAN IGG,4000454,CDM,302,RC,86747,HCPCS,Outpatient,,,131.33,65.67,,85.36,65,,68.288,Percent of Total Billed Charges,65% of Total Billed Charges,89.3,68,,71.44,Percent of Total Billed Charges,68% of Total Billed Charges,21.33,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.27,20,,21.016,Percent of Total Billed Charges,20% of Total Billed Charges,26.27,20,,21.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.27,20,,21.016,Percent of Total Billed Charges,20% of Total Billed Charges,26.27,20,,21.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.36,65,,68.288,Percent of Total Billed Charges,65% of Total Billed Charges,85.36,65,,68.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.67,50,,52.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.33,89.3,
NT-PROBNP,4000456,CDM,301,RC,83880,HCPCS,Outpatient,,,206,103.00,,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,140.08,68,,112.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,50,,82.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,140.08,
VIT D 125 DIHYDROXY,4000457,CDM,301,RC,82652,HCPCS,Outpatient,,,59.74,29.87,,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,40.62,68,,32.496,Percent of Total Billed Charges,68% of Total Billed Charges,54.63,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,11.95,20,,9.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,38.83,65,,31.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.87,50,,23.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,54.63,
VITAMIN D,4000459,CDM,301,RC,82306,HCPCS,Outpatient,,,100.94,50.47,,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,68.64,68,,54.912,Percent of Total Billed Charges,68% of Total Billed Charges,42.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.47,50,,40.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,68.64,
PROTEIN URINE RANDOM,4000461,CDM,301,RC,84156,HCPCS,Outpatient,,,32.96,16.48,,21.42,65,,17.136,Percent of Total Billed Charges,65% of Total Billed Charges,22.41,68,,17.928,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.59,20,,5.272,Percent of Total Billed Charges,20% of Total Billed Charges,6.59,20,,5.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.59,20,,5.272,Percent of Total Billed Charges,20% of Total Billed Charges,6.59,20,,5.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.42,65,,17.136,Percent of Total Billed Charges,65% of Total Billed Charges,21.42,65,,17.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,50,,13.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.59,22.41,
GLYCOMARK,4000463,CDM,301,RC,84378,HCPCS,Outpatient,,,133.9,66.95,,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,68,,72.84,Percent of Total Billed Charges,68% of Total Billed Charges,11.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,50,,53.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.05,91.05,
LEVETIRACETAM (KEPPRA),4000465,CDM,301,RC,82542,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,24.09,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,63.04,
OXYCARBAMAZEPINE,4000469,CDM,301,RC,80157,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,49.03,
ANTITRYPSIN ALPA 1,4000473,CDM,301,RC,82103,HCPCS,Outpatient,,,55.62,27.81,,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,37.82,68,,30.256,Percent of Total Billed Charges,68% of Total Billed Charges,19.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,11.12,20,,8.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,36.15,65,,28.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.81,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,37.82,
FEBRILE AGGLUTININS,4000475,CDM,302,RC,86000,HCPCS,Outpatient,,,111.24,55.62,,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,75.64,68,,60.512,Percent of Total Billed Charges,68% of Total Billed Charges,9.91,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,22.25,20,,17.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,72.31,65,,57.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.62,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.91,75.64,
ANA IFA SCREEN WITH REFLEX TO TITER,4000477,CDM,302,RC,86038,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,17.15,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,42.02,
ASO,4000479,CDM,302,RC,86060,HCPCS,Outpatient,,,66.95,33.48,,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,68,,36.424,Percent of Total Billed Charges,68% of Total Billed Charges,10.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,50,,26.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.36,45.53,
COLD AGGLUTININS,4000481,CDM,302,RC,86156,HCPCS,Outpatient,,,76.22,38.11,,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,51.83,68,,41.464,Percent of Total Billed Charges,68% of Total Billed Charges,9.51,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,50,,30.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.51,51.83,
C REACTIVE PROTEIN (QUEST),4000483,CDM,302,RC,86140,HCPCS,Outpatient,,,56.65,28.33,,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,38.52,68,,30.816,Percent of Total Billed Charges,68% of Total Billed Charges,7.34,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.33,50,,22.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,38.52,
FTA-ABS,4000485,CDM,302,RC,86780,HCPCS,Outpatient,,,70.04,35.02,,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,47.63,68,,38.104,Percent of Total Billed Charges,68% of Total Billed Charges,18.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,50,,28.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,47.63,
HETEROPHILE MONO SCREEN,4000487,CDM,302,RC,86308,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,7.34,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,28.02,
RPR (RAPID PLASMA REAGIN),4000491,CDM,302,RC,86592,HCPCS,Outpatient,,,36.05,18.03,,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,24.51,68,,19.608,Percent of Total Billed Charges,68% of Total Billed Charges,6.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,50,,14.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.06,24.51,
WESTERN BLOT,4000493,CDM,302,RC,86689,HCPCS,Outpatient,,,163.77,81.89,,106.45,65,,85.16,Percent of Total Billed Charges,65% of Total Billed Charges,111.36,68,,89.088,Percent of Total Billed Charges,68% of Total Billed Charges,27.47,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,32.75,20,,26.2,Percent of Total Billed Charges,20% of Total Billed Charges,32.75,20,,26.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.75,20,,26.2,Percent of Total Billed Charges,20% of Total Billed Charges,32.75,20,,26.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.45,65,,85.16,Percent of Total Billed Charges,65% of Total Billed Charges,106.45,65,,85.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.89,50,,65.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.47,111.36,
CANCER AG 125,4000495,CDM,302,RC,86304,HCPCS,Outpatient,,,121.54,60.77,,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,82.65,68,,66.12,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.77,50,,48.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,82.65,
HIV AB/AG 4TH GENERATION,4000497,CDM,302,RC,86701,HCPCS,Outpatient,,,73.13,36.57,,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,49.73,68,,39.784,Percent of Total Billed Charges,68% of Total Billed Charges,12.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,50,,29.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.61,49.73,
MYCOPLASMA BLD,4000499,CDM,302,RC,86738,HCPCS,Outpatient,,,97.85,48.93,,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,66.54,68,,53.232,Percent of Total Billed Charges,68% of Total Billed Charges,18.8,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.93,50,,39.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,66.54,
T4 LYMPHOCYTES,4000501,CDM,302,RC,86360,HCPCS,Outpatient,,,291.49,145.75,,189.47,65,,151.576,Percent of Total Billed Charges,65% of Total Billed Charges,198.21,68,,158.568,Percent of Total Billed Charges,68% of Total Billed Charges,9.66,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,58.3,20,,46.64,Percent of Total Billed Charges,20% of Total Billed Charges,58.3,20,,46.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.3,20,,46.64,Percent of Total Billed Charges,20% of Total Billed Charges,58.3,20,,46.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.47,65,,151.576,Percent of Total Billed Charges,65% of Total Billed Charges,189.47,65,,151.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.75,50,,116.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,198.21,
LYME DISEASE TITER,4000503,CDM,302,RC,86618,HCPCS,Outpatient,,,140.08,70.04,,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,95.25,68,,76.2,Percent of Total Billed Charges,68% of Total Billed Charges,20.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,28.02,20,,22.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,65,,72.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.04,50,,56.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,95.25,
EBV AB 1GM VCA,4000505,CDM,302,RC,86665,HCPCS,Outpatient,,,185.4,92.70,,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,126.07,68,,100.856,Percent of Total Billed Charges,68% of Total Billed Charges,25.75,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,37.08,20,,29.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,120.51,65,,96.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.7,50,,74.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,126.07,
ANTICARDIOLIPIN,4000507,CDM,302,RC,86147,HCPCS,Outpatient,,,194.67,97.34,,126.54,65,,101.232,Percent of Total Billed Charges,65% of Total Billed Charges,132.38,68,,105.904,Percent of Total Billed Charges,68% of Total Billed Charges,22.87,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,38.93,20,,31.144,Percent of Total Billed Charges,20% of Total Billed Charges,38.93,20,,31.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.93,20,,31.144,Percent of Total Billed Charges,20% of Total Billed Charges,38.93,20,,31.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.54,65,,101.232,Percent of Total Billed Charges,65% of Total Billed Charges,126.54,65,,101.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.34,50,,77.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.87,132.38,
COMPLEMENT C-H (50),4000509,CDM,302,RC,86162,HCPCS,Outpatient,,,121.54,60.77,,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,82.65,68,,66.12,Percent of Total Billed Charges,68% of Total Billed Charges,28.83,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.77,50,,48.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,82.65,
VARICELLA ZOSTER,4000511,CDM,302,RC,86787,HCPCS,Outpatient,,,103,51.50,,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,70.04,68,,56.032,Percent of Total Billed Charges,68% of Total Billed Charges,18.29,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.29,70.04,
DNA DOUBLE STRANDED,4000513,CDM,302,RC,86225,HCPCS,Outpatient,,,91.67,45.84,,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,62.34,68,,49.872,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.84,50,,36.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.33,62.34,
RSV TITER,4000515,CDM,302,RC,86756,HCPCS,Outpatient,,,116.39,58.20,,75.65,65,,60.52,Percent of Total Billed Charges,65% of Total Billed Charges,79.15,68,,63.32,Percent of Total Billed Charges,68% of Total Billed Charges,18.29,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,23.28,20,,18.624,Percent of Total Billed Charges,20% of Total Billed Charges,23.28,20,,18.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.28,20,,18.624,Percent of Total Billed Charges,20% of Total Billed Charges,23.28,20,,18.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.65,65,,60.52,Percent of Total Billed Charges,65% of Total Billed Charges,75.65,65,,60.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.2,50,,46.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.29,79.15,
CMV IGG AB,4000517,CDM,302,RC,86644,HCPCS,Outpatient,,,90.64,45.32,,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,61.64,68,,49.312,Percent of Total Billed Charges,68% of Total Billed Charges,20.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,50,,36.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,61.64,
RESPIRATORY VIRUS PROFILE,4000520,CDM,306,RC,87633,HCPCS,Outpatient,,,757.05,378.53,,492.08,65,,393.664,Percent of Total Billed Charges,65% of Total Billed Charges,514.79,68,,411.832,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.41,20,,121.128,Percent of Total Billed Charges,20% of Total Billed Charges,151.41,20,,121.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.41,20,,121.128,Percent of Total Billed Charges,20% of Total Billed Charges,151.41,20,,121.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.08,65,,393.664,Percent of Total Billed Charges,65% of Total Billed Charges,492.08,65,,393.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.53,50,,302.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.41,514.79,
CA 15-3,4000523,CDM,302,RC,86300,HCPCS,Outpatient,,,164.8,82.40,,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,112.06,68,,89.648,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.4,50,,65.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,112.06,
COMPLEMENT C-4 OR C3,4000525,CDM,302,RC,86160,HCPCS,Outpatient,,,73.13,36.57,,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,49.73,68,,39.784,Percent of Total Billed Charges,68% of Total Billed Charges,17.04,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,50,,29.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,49.73,
LEGIONELLA TITER,4000527,CDM,302,RC,86713,HCPCS,Outpatient,,,216.3,108.15,,140.6,65,,112.48,Percent of Total Billed Charges,65% of Total Billed Charges,147.08,68,,117.664,Percent of Total Billed Charges,68% of Total Billed Charges,21.72,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,43.26,20,,34.608,Percent of Total Billed Charges,20% of Total Billed Charges,43.26,20,,34.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.26,20,,34.608,Percent of Total Billed Charges,20% of Total Billed Charges,43.26,20,,34.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.6,65,,112.48,Percent of Total Billed Charges,65% of Total Billed Charges,140.6,65,,112.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.15,50,,86.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.72,147.08,
RAST SOUTHEAST REGIO,4000529,CDM,302,RC,86003,HCPCS,Outpatient,,,307.97,153.99,,200.18,65,,160.144,Percent of Total Billed Charges,65% of Total Billed Charges,209.42,68,,167.536,Percent of Total Billed Charges,68% of Total Billed Charges,7.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,61.59,20,,49.272,Percent of Total Billed Charges,20% of Total Billed Charges,61.59,20,,49.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,20,,49.272,Percent of Total Billed Charges,20% of Total Billed Charges,61.59,20,,49.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.18,65,,160.144,Percent of Total Billed Charges,65% of Total Billed Charges,200.18,65,,160.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.99,50,,123.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,209.42,
RAST SALAD GROUP,4000531,CDM,302,RC,86003,HCPCS,Outpatient,,,173.04,86.52,,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,117.67,68,,94.136,Percent of Total Billed Charges,68% of Total Billed Charges,7.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.52,50,,69.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,117.67,
RAST VEGETABLE GROUP,4000533,CDM,302,RC,86003,HCPCS,Outpatient,,,173.04,86.52,,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,117.67,68,,94.136,Percent of Total Billed Charges,68% of Total Billed Charges,7.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.52,50,,69.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,117.67,
RAST ALLERGY GROUP,4000535,CDM,302,RC,86005,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,11.32,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.26,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.32,58.83,
MUMPS VIRUS IGG,4000537,CDM,302,RC,86735,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,18.52,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
RUBELLA VIRUS IGG,4000539,CDM,302,RC,86762,HCPCS,Outpatient,,,57.68,28.84,,37.49,65,,29.992,Percent of Total Billed Charges,65% of Total Billed Charges,39.22,68,,31.376,Percent of Total Billed Charges,68% of Total Billed Charges,20.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.54,20,,9.232,Percent of Total Billed Charges,20% of Total Billed Charges,11.54,20,,9.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,20,,9.232,Percent of Total Billed Charges,20% of Total Billed Charges,11.54,20,,9.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.49,65,,29.992,Percent of Total Billed Charges,65% of Total Billed Charges,37.49,65,,29.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.84,50,,23.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,39.22,
RUBEOLA VIRUS IGG,4000541,CDM,302,RC,86765,HCPCS,Outpatient,,,95.17,47.59,,61.86,65,,49.488,Percent of Total Billed Charges,65% of Total Billed Charges,64.72,68,,51.776,Percent of Total Billed Charges,68% of Total Billed Charges,18.29,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.03,20,,15.224,Percent of Total Billed Charges,20% of Total Billed Charges,19.03,20,,15.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,20,,15.224,Percent of Total Billed Charges,20% of Total Billed Charges,19.03,20,,15.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.86,65,,49.488,Percent of Total Billed Charges,65% of Total Billed Charges,61.86,65,,49.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.59,50,,38.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.29,64.72,
TOXOPLASMA IGM,4000543,CDM,302,RC,86778,HCPCS,Outpatient,,,177.16,88.58,,115.15,65,,92.12,Percent of Total Billed Charges,65% of Total Billed Charges,120.47,68,,96.376,Percent of Total Billed Charges,68% of Total Billed Charges,20.44,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,35.43,20,,28.344,Percent of Total Billed Charges,20% of Total Billed Charges,35.43,20,,28.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.43,20,,28.344,Percent of Total Billed Charges,20% of Total Billed Charges,35.43,20,,28.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.15,65,,92.12,Percent of Total Billed Charges,65% of Total Billed Charges,115.15,65,,92.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.58,50,,70.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.44,120.47,
CMV IGM AB,4000545,CDM,302,RC,86645,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,23.91,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
H. PYLORI AB,4000547,CDM,302,RC,86677,HCPCS,Outpatient,,,50.99,25.50,,33.14,65,,26.512,Percent of Total Billed Charges,65% of Total Billed Charges,34.67,68,,27.736,Percent of Total Billed Charges,68% of Total Billed Charges,20.6,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.14,65,,26.512,Percent of Total Billed Charges,65% of Total Billed Charges,33.14,65,,26.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,34.67,
HSV1 IGG SER EIA-ACNC,4000549,CDM,302,RC,86695,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,18.72,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
SINGLE RAST,4000551,CDM,302,RC,86003,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,7.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,36.42,
HEP B SURFACE AB QUAL,4000553,CDM,302,RC,86706,HCPCS,Outpatient,,,64.89,32.45,,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,44.13,68,,35.304,Percent of Total Billed Charges,68% of Total Billed Charges,14.84,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.45,50,,25.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,44.13,
HEP A IGM AB,4000555,CDM,302,RC,86709,HCPCS,Outpatient,,,81.37,40.69,,52.89,65,,42.312,Percent of Total Billed Charges,65% of Total Billed Charges,55.33,68,,44.264,Percent of Total Billed Charges,68% of Total Billed Charges,15.55,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.89,65,,42.312,Percent of Total Billed Charges,65% of Total Billed Charges,52.89,65,,42.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.69,50,,32.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.55,55.33,
HEP A AB IGG & IGM,4000557,CDM,302,RC,86708,HCPCS,Outpatient,,,73.13,36.57,,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,49.73,68,,39.784,Percent of Total Billed Charges,68% of Total Billed Charges,17.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,50,,29.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,49.73,
HEP A AB TOTAL,4000559,CDM,302,RC,86708,HCPCS,Outpatient,,,73.13,36.57,,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,49.73,68,,39.784,Percent of Total Billed Charges,68% of Total Billed Charges,17.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,50,,29.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,49.73,
HEP B CORE IGM AB,4000561,CDM,302,RC,86705,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,16.27,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.75,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,58.13,
HEPATITIS C ANTIBODY,4000563,CDM,302,RC,86803,HCPCS,Outpatient,,,93.73,46.87,,60.92,65,,48.736,Percent of Total Billed Charges,65% of Total Billed Charges,63.74,68,,50.992,Percent of Total Billed Charges,68% of Total Billed Charges,19.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.75,20,,15,Percent of Total Billed Charges,20% of Total Billed Charges,18.75,20,,15,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.75,20,,15,Percent of Total Billed Charges,20% of Total Billed Charges,18.75,20,,15,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.92,65,,48.736,Percent of Total Billed Charges,65% of Total Billed Charges,60.92,65,,48.736,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,50,,37.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.75,63.74,
HEP BE ANTIBODY,4000565,CDM,302,RC,86707,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,15.98,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
HEP B CORE ANTIBODY,4000567,CDM,302,RC,86704,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,16.66,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
HEP B SUR ANTIBODY,4000569,CDM,302,RC,86706,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,14.84,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
ANTI SMITH,4000577,CDM,302,RC,86235,HCPCS,Outpatient,,,115.36,57.68,,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,78.44,68,,62.752,Percent of Total Billed Charges,68% of Total Billed Charges,25.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,50,,46.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,78.44,
RNP ANTIBODY,4000579,CDM,302,RC,86235,HCPCS,Outpatient,,,115.36,57.68,,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,78.44,68,,62.752,Percent of Total Billed Charges,68% of Total Billed Charges,25.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,50,,46.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,78.44,
SJOGRENS ANTIBODY (SS-A),4000581,CDM,302,RC,86235,HCPCS,Outpatient,,,115.36,57.68,,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,78.44,68,,62.752,Percent of Total Billed Charges,68% of Total Billed Charges,25.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,50,,46.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,78.44,
SJOGRENS ANTIBODY (SS-B),4000583,CDM,302,RC,86235,HCPCS,Outpatient,,,115.36,57.68,,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,78.44,68,,62.752,Percent of Total Billed Charges,68% of Total Billed Charges,25.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,23.07,20,,18.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,74.98,65,,59.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,50,,46.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.07,78.44,
C TRACHOMATIS IGM AB,4000589,CDM,302,RC,86632,HCPCS,Outpatient,,,89.61,44.81,,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,60.93,68,,48.744,Percent of Total Billed Charges,68% of Total Billed Charges,18.02,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,17.92,20,,14.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,58.25,65,,46.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.81,50,,35.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,60.93,
RAST SINGLE TEST IGE,4000591,CDM,302,RC,86003,HCPCS,Outpatient,,,54.59,27.30,,35.48,65,,28.384,Percent of Total Billed Charges,65% of Total Billed Charges,37.12,68,,29.696,Percent of Total Billed Charges,68% of Total Billed Charges,7.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,10.92,20,,8.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.48,65,,28.384,Percent of Total Billed Charges,65% of Total Billed Charges,35.48,65,,28.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.3,50,,21.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,37.12,
HISTOPLASMA AB CF,4000595,CDM,302,RC,86698,HCPCS,Outpatient,,,96.82,48.41,,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,65.84,68,,52.672,Percent of Total Billed Charges,68% of Total Billed Charges,17.75,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.41,50,,38.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.75,65.84,
ANITBODY ELUTION,4000597,CDM,309,RC,86860,HCPCS,Outpatient,,,101.97,50.99,,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,69.34,68,,55.472,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,50,,40.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.39,69.34,
LACTIC ACID,4000598,CDM,301,RC,83605,HCPCS,Outpatient,,,96.82,48.41,,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,65.84,68,,52.672,Percent of Total Billed Charges,68% of Total Billed Charges,15.15,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.41,50,,38.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.15,65.84,
CA-19-9,4000599,CDM,302,RC,86301,HCPCS,Outpatient,,,104.03,52.02,,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,70.74,68,,56.592,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.02,50,,41.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,70.74,
AMMONIA PLASMA,4000600,CDM,302,RC,82140,HCPCS,Outpatient,,,96.82,48.41,,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,65.84,68,,52.672,Percent of Total Billed Charges,68% of Total Billed Charges,20.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.41,50,,38.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,65.84,
ROCKY MOUNT SPOT FEV,4000601,CDM,302,RC,86000,HCPCS,Outpatient,,,100.94,50.47,,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,68.64,68,,54.912,Percent of Total Billed Charges,68% of Total Billed Charges,9.91,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.47,50,,40.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.91,68.64,
ALLERGEN TREE,4000603,CDM,302,RC,86003,HCPCS,Outpatient,,,27.81,13.91,,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,18.91,68,,15.128,Percent of Total Billed Charges,68% of Total Billed Charges,7.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.91,50,,11.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,18.91,
ALLERGEN GRASSES,4000605,CDM,302,RC,86003,HCPCS,Outpatient,,,27.81,13.91,,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,18.91,68,,15.128,Percent of Total Billed Charges,68% of Total Billed Charges,7.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,5.56,20,,4.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,18.08,65,,14.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.91,50,,11.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,18.91,
ALLERGY SC MOLD/ANIM,4000607,CDM,302,RC,86005,HCPCS,Outpatient,,,73.13,36.57,,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,49.73,68,,39.784,Percent of Total Billed Charges,68% of Total Billed Charges,11.32,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,14.63,20,,11.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,47.53,65,,38.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,50,,29.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.32,49.73,
LYME DISEASE AB W/REFLEX TO BLOT,4000609,CDM,302,RC,86617,HCPCS,Outpatient,,,125.66,62.83,,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,85.45,68,,68.36,Percent of Total Billed Charges,68% of Total Billed Charges,21.98,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,50,,50.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.98,85.45,
LYME DISEASE AB W/RFLX TO IMMUNOASSAY,4000610,CDM,302,RC,86617,HCPCS,Outpatient,,,125.66,62.83,,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,85.45,68,,68.36,Percent of Total Billed Charges,68% of Total Billed Charges,21.98,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,25.13,20,,20.104,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,81.68,65,,65.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,50,,50.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.98,85.45,
CD4 & CD8,4000611,CDM,302,RC,86360,HCPCS,Outpatient,,,174.07,87.04,,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,118.37,68,,94.696,Percent of Total Billed Charges,68% of Total Billed Charges,9.66,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,50,,69.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,118.37,
T CELLS COUNT,4000613,CDM,302,RC,86359,HCPCS,Outpatient,,,101.97,50.99,,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,69.34,68,,55.472,Percent of Total Billed Charges,68% of Total Billed Charges,4.42,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,20.39,20,,16.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,66.28,65,,53.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,50,,40.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.42,69.34,
EBV IGG VCA,4000615,CDM,302,RC,86665,HCPCS,Outpatient,,,165.83,82.92,,107.79,65,,86.232,Percent of Total Billed Charges,65% of Total Billed Charges,112.76,68,,90.208,Percent of Total Billed Charges,68% of Total Billed Charges,25.75,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,33.17,20,,26.536,Percent of Total Billed Charges,20% of Total Billed Charges,33.17,20,,26.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.17,20,,26.536,Percent of Total Billed Charges,20% of Total Billed Charges,33.17,20,,26.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.79,65,,86.232,Percent of Total Billed Charges,65% of Total Billed Charges,107.79,65,,86.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.92,50,,66.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,112.76,
HSV2 IGG SER EIA-ACNC,4000617,CDM,302,RC,86696,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
T CELLS TOTAL COUNT,4000621,CDM,302,RC,86359,HCPCS,Outpatient,,,226.6,113.30,,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,154.09,68,,123.272,Percent of Total Billed Charges,68% of Total Billed Charges,4.42,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.3,50,,90.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.42,154.09,
CD4/CD8 INC RATIO,4000623,CDM,302,RC,86360,HCPCS,Outpatient,,,226.6,113.30,,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,154.09,68,,123.272,Percent of Total Billed Charges,68% of Total Billed Charges,9.66,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.3,50,,90.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,154.09,
ALLERGEN PROFILE ZN4,4000625,CDM,302,RC,86003,HCPCS,Outpatient,,,414.58,207.29,,269.48,65,,215.584,Percent of Total Billed Charges,65% of Total Billed Charges,281.91,68,,225.528,Percent of Total Billed Charges,68% of Total Billed Charges,7.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,82.92,20,,66.336,Percent of Total Billed Charges,20% of Total Billed Charges,82.92,20,,66.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.92,20,,66.336,Percent of Total Billed Charges,20% of Total Billed Charges,82.92,20,,66.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.48,65,,215.584,Percent of Total Billed Charges,65% of Total Billed Charges,269.48,65,,215.584,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.29,50,,165.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,281.91,
CHLAMYDIA AB IGG,4000627,CDM,302,RC,86631,HCPCS,Outpatient,,,42.95,21.48,,27.92,65,,22.336,Percent of Total Billed Charges,65% of Total Billed Charges,29.21,68,,23.368,Percent of Total Billed Charges,68% of Total Billed Charges,16.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.59,20,,6.872,Percent of Total Billed Charges,20% of Total Billed Charges,8.59,20,,6.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.59,20,,6.872,Percent of Total Billed Charges,20% of Total Billed Charges,8.59,20,,6.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.92,65,,22.336,Percent of Total Billed Charges,65% of Total Billed Charges,27.92,65,,22.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.48,50,,17.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.59,29.21,
RSV ANTIGEN (DFA)-NASOPHARYNGEAL,4000629,CDM,302,RC,86317,HCPCS,Outpatient,,,87.55,43.78,,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,59.53,68,,47.624,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.78,50,,35.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,59.53,
INFLUENZA AB (BLOOD),4000631,CDM,302,RC,86710,HCPCS,Outpatient,,,51.5,25.75,,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,68,,28.016,Percent of Total Billed Charges,68% of Total Billed Charges,19.24,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,50,,20.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,35.02,
VARICELLA IGM,4000633,CDM,302,RC,86787,HCPCS,Outpatient,,,39.14,19.57,,25.44,65,,20.352,Percent of Total Billed Charges,65% of Total Billed Charges,26.62,68,,21.296,Percent of Total Billed Charges,68% of Total Billed Charges,18.29,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,7.83,20,,6.264,Percent of Total Billed Charges,20% of Total Billed Charges,7.83,20,,6.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.83,20,,6.264,Percent of Total Billed Charges,20% of Total Billed Charges,7.83,20,,6.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.44,65,,20.352,Percent of Total Billed Charges,65% of Total Billed Charges,25.44,65,,20.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,50,,15.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.83,26.62,
LACOSAMIDE LEVEL,4000635,CDM,301,RC,80299,HCPCS,Outpatient,,,249.21,124.61,,161.99,65,,129.592,Percent of Total Billed Charges,65% of Total Billed Charges,169.46,68,,135.568,Percent of Total Billed Charges,68% of Total Billed Charges,19.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,49.84,20,,39.872,Percent of Total Billed Charges,20% of Total Billed Charges,49.84,20,,39.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.84,20,,39.872,Percent of Total Billed Charges,20% of Total Billed Charges,49.84,20,,39.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.99,65,,129.592,Percent of Total Billed Charges,65% of Total Billed Charges,161.99,65,,129.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.61,50,,99.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.43,169.46,
APTT,4000637,CDM,305,RC,85730,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,8.52,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.52,42.02,
BLEEDING TIME,4000639,CDM,305,RC,85002,HCPCS,Outpatient,,,49.44,24.72,,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,33.62,68,,26.896,Percent of Total Billed Charges,68% of Total Billed Charges,6.39,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,50,,19.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,33.62,
CBC W AUTO DIFF,4000641,CDM,305,RC,85025,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,11.04,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
DAILY CBC W AUTO DIFF,4000642,CDM,305,RC,85025,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,11.04,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
.DIFFERENTIAL SMEAR,4000643,CDM,305,RC,85007,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,4.89,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.89,17.51,
SEDIMENTATION RATE,4000645,CDM,305,RC,85652,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,3.83,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.83,31.52,
PROTIME,4000649,CDM,305,RC,85610,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,5.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.58,42.02,
RETICULOCYTE COUNT,4000651,CDM,305,RC,85044,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,6.1,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,17.51,
SICKLE CELL SCREEN,4000653,CDM,305,RC,85660,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,7.84,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.84,28.02,
FIBRINOGEN PPP-MCNC,4000655,CDM,305,RC,85384,HCPCS,Outpatient,,,69.01,34.51,,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,46.93,68,,37.544,Percent of Total Billed Charges,68% of Total Billed Charges,12.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.51,50,,27.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,46.93,
LUPUS PROFILE,4000657,CDM,305,RC,85705,HCPCS,Outpatient,,,130.81,65.41,,85.03,65,,68.024,Percent of Total Billed Charges,65% of Total Billed Charges,88.95,68,,71.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,26.16,20,,20.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.03,65,,68.024,Percent of Total Billed Charges,65% of Total Billed Charges,85.03,65,,68.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.41,50,,52.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.05,88.95,
PROTEIN S & C PANEL,4000659,CDM,305,RC,85303,HCPCS,Outpatient,,,344.02,172.01,,223.61,65,,178.888,Percent of Total Billed Charges,65% of Total Billed Charges,233.93,68,,187.144,Percent of Total Billed Charges,68% of Total Billed Charges,19.63,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,68.8,20,,55.04,Percent of Total Billed Charges,20% of Total Billed Charges,68.8,20,,55.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.8,20,,55.04,Percent of Total Billed Charges,20% of Total Billed Charges,68.8,20,,55.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.61,65,,178.888,Percent of Total Billed Charges,65% of Total Billed Charges,223.61,65,,178.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.01,50,,137.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.63,233.93,
ABSOLUTE NEUTROPHIL COUNT,4000662,CDM,305,RC,85048,HCPCS,Outpatient,,,24.72,12.36,,16.07,65,,12.856,Percent of Total Billed Charges,65% of Total Billed Charges,16.81,68,,13.448,Percent of Total Billed Charges,68% of Total Billed Charges,3.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,65,,12.856,Percent of Total Billed Charges,65% of Total Billed Charges,16.07,65,,12.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,16.81,
ANTITHROMBIN III ACT,4000663,CDM,305,RC,85300,HCPCS,Outpatient,,,173.04,86.52,,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,117.67,68,,94.136,Percent of Total Billed Charges,68% of Total Billed Charges,8.03,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.52,50,,69.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,117.67,
ANTITHROMBIN III AB,4000665,CDM,305,RC,85301,HCPCS,Outpatient,,,173.04,86.52,,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,117.67,68,,94.136,Percent of Total Billed Charges,68% of Total Billed Charges,15.35,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.52,50,,69.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,117.67,
PLATELET COUNT,4000667,CDM,305,RC,85032,HCPCS,Outpatient,,,350.2,175.10,,227.63,65,,182.104,Percent of Total Billed Charges,65% of Total Billed Charges,238.14,68,,190.512,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.04,20,,56.032,Percent of Total Billed Charges,20% of Total Billed Charges,70.04,20,,56.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.04,20,,56.032,Percent of Total Billed Charges,20% of Total Billed Charges,70.04,20,,56.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227.63,65,,182.104,Percent of Total Billed Charges,65% of Total Billed Charges,227.63,65,,182.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.1,50,,140.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.04,238.14,
WBC COUNT,4000671,CDM,305,RC,85048,HCPCS,Outpatient,,,20.6,10.30,,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,14.01,68,,11.208,Percent of Total Billed Charges,68% of Total Billed Charges,3.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,50,,8.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,14.01,
THROMBIN,4000673,CDM,305,RC,85670,HCPCS,Outpatient,,,70.04,35.02,,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,47.63,68,,38.104,Percent of Total Billed Charges,68% of Total Billed Charges,8.03,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,50,,28.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,47.63,
F D P,4000675,CDM,305,RC,85362,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,9.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
CBC MANUAL DIFFERENTIAL ONLY,4000677,CDM,305,RC,85007,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,4.89,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.89,31.52,
D-DIMER QUANTITATIVE,4000679,CDM,305,RC,85378,HCPCS,Outpatient,,,128.75,64.38,,83.69,65,,66.952,Percent of Total Billed Charges,65% of Total Billed Charges,87.55,68,,70.04,Percent of Total Billed Charges,68% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,25.75,20,,20.6,Percent of Total Billed Charges,20% of Total Billed Charges,25.75,20,,20.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,20,,20.6,Percent of Total Billed Charges,20% of Total Billed Charges,25.75,20,,20.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.69,65,,66.952,Percent of Total Billed Charges,65% of Total Billed Charges,83.69,65,,66.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.38,50,,51.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.12,87.55,
HEMOGLOBIN,4000681,CDM,305,RC,85018,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,3.35,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
HEMATOCRIT,4000683,CDM,305,RC,85014,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,3.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
PLATELET COUNT,4000685,CDM,305,RC,85049,HCPCS,Outpatient,,,20.6,10.30,,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,14.01,68,,11.208,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,50,,8.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,14.01,
FACTOR V,4000687,CDM,305,RC,85220,HCPCS,Outpatient,,,183.86,91.93,,119.51,65,,95.608,Percent of Total Billed Charges,65% of Total Billed Charges,125.02,68,,100.016,Percent of Total Billed Charges,68% of Total Billed Charges,25.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,36.77,20,,29.416,Percent of Total Billed Charges,20% of Total Billed Charges,36.77,20,,29.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.77,20,,29.416,Percent of Total Billed Charges,20% of Total Billed Charges,36.77,20,,29.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.51,65,,95.608,Percent of Total Billed Charges,65% of Total Billed Charges,119.51,65,,95.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.93,50,,73.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.05,125.02,
GC CULTURE E,4000689,CDM,306,RC,87070,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,49.03,
OVA AND PARASITE EXAM,4000693,CDM,306,RC,87177,HCPCS,Outpatient,,,128.75,64.38,,83.69,65,,66.952,Percent of Total Billed Charges,65% of Total Billed Charges,87.55,68,,70.04,Percent of Total Billed Charges,68% of Total Billed Charges,12.63,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,25.75,20,,20.6,Percent of Total Billed Charges,20% of Total Billed Charges,25.75,20,,20.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,20,,20.6,Percent of Total Billed Charges,20% of Total Billed Charges,25.75,20,,20.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.69,65,,66.952,Percent of Total Billed Charges,65% of Total Billed Charges,83.69,65,,66.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.38,50,,51.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.63,87.55,
PIN WORM PREP,4000695,CDM,306,RC,87172,HCPCS,Outpatient,,,51.5,25.75,,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,68,,28.016,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,50,,20.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,35.02,
ACID FAST STN,4000697,CDM,306,RC,87206,HCPCS,Outpatient,,,90.64,45.32,,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,61.64,68,,49.312,Percent of Total Billed Charges,68% of Total Billed Charges,7.62,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,50,,36.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,61.64,
AFB SPUTUM CULTURE,4000699,CDM,306,RC,87116,HCPCS,Outpatient,,,81.37,40.69,,52.89,65,,42.312,Percent of Total Billed Charges,65% of Total Billed Charges,55.33,68,,44.264,Percent of Total Billed Charges,68% of Total Billed Charges,15.34,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,16.27,20,,13.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.89,65,,42.312,Percent of Total Billed Charges,65% of Total Billed Charges,52.89,65,,42.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.69,50,,32.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.34,55.33,
ROUTINE CULTURE-THROAT SWAB,4000701,CDM,306,RC,87081,HCPCS,Outpatient,,,42.23,21.12,,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,28.72,68,,22.976,Percent of Total Billed Charges,68% of Total Billed Charges,9.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.12,50,,16.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,28.72,
BLOOD CULTURE,4000703,CDM,306,RC,87040,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,14.65,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.65,63.04,
CATH TUBE CULTURE,4000705,CDM,306,RC,87070,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
FUNGAL CULTURE (SBH),4000707,CDM,306,RC,87102,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,11.92,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.92,63.04,
GRAM STAIN,4000709,CDM,306,RC,87205,HCPCS,Outpatient,,,30.9,15.45,,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,21.01,68,,16.808,Percent of Total Billed Charges,68% of Total Billed Charges,6.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,50,,12.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.06,21.01,
SENSITIVITY,4000711,CDM,306,RC,87184,HCPCS,Outpatient,,,56.65,28.33,,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,38.52,68,,30.816,Percent of Total Billed Charges,68% of Total Billed Charges,9.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.33,50,,22.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.79,38.52,
CHLAMYDIA CULTURE,4000713,CDM,306,RC,87110,HCPCS,Outpatient,,,151.82,75.91,,98.68,65,,78.944,Percent of Total Billed Charges,65% of Total Billed Charges,103.24,68,,82.592,Percent of Total Billed Charges,68% of Total Billed Charges,23.47,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.36,20,,24.288,Percent of Total Billed Charges,20% of Total Billed Charges,30.36,20,,24.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.36,20,,24.288,Percent of Total Billed Charges,20% of Total Billed Charges,30.36,20,,24.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.68,65,,78.944,Percent of Total Billed Charges,65% of Total Billed Charges,98.68,65,,78.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.91,50,,60.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.47,103.24,
CULTURE HERPES,4000715,CDM,306,RC,87207,HCPCS,Outpatient,,,108.15,54.08,,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,73.54,68,,58.832,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.08,50,,43.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,73.54,
RAPID STREP A  ANTIGEN,4000717,CDM,306,RC,87430,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,17.51,
RAPID STREP A RNA,4000718,CDM,306,RC,87651,HCPCS,Outpatient,,,169.95,84.98,,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,115.57,68,,92.456,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.98,50,,67.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,115.57,
QUEST CULTURE - STOOL,4000719,CDM,306,RC,87045,HCPCS,Outpatient,,,97.85,48.93,,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,66.54,68,,53.232,Percent of Total Billed Charges,68% of Total Billed Charges,13.39,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.93,50,,39.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,66.54,
C DIFF TOXIN/GDH WITH REFLEX TO PCR RL,4000723,CDM,306,RC,87324,HCPCS,Outpatient,,,113.3,56.65,,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,77.04,68,,61.632,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.65,50,,45.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,77.04,
CULTURE VIRAL,4000725,CDM,306,RC,87252,HCPCS,Outpatient,,,226.6,113.30,,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,154.09,68,,123.272,Percent of Total Billed Charges,68% of Total Billed Charges,37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.3,50,,90.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,154.09,
HEP B SURFACE ANTIGE,4000729,CDM,306,RC,87340,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,14.27,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
HEP BE ANTIGEN,4000731,CDM,306,RC,87350,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,15.92,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
HIV-1 RNA,4000733,CDM,306,RC,87536,HCPCS,Outpatient,,,267.8,133.90,,174.07,65,,139.256,Percent of Total Billed Charges,65% of Total Billed Charges,182.1,68,,145.68,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,20,,42.848,Percent of Total Billed Charges,20% of Total Billed Charges,53.56,20,,42.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,20,,42.848,Percent of Total Billed Charges,20% of Total Billed Charges,53.56,20,,42.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.07,65,,139.256,Percent of Total Billed Charges,65% of Total Billed Charges,174.07,65,,139.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,50,,107.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,182.1,
ROTAVIRUS ANTIGEN,4000737,CDM,306,RC,87425,HCPCS,Outpatient,,,109.18,54.59,,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,74.24,68,,59.392,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.59,50,,43.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,74.24,
WET PREP VAGINAL,4000739,CDM,306,RC,87210,HCPCS,Outpatient,,,23.69,11.85,,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,16.11,68,,12.888,Percent of Total Billed Charges,68% of Total Billed Charges,6.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,4.74,20,,3.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,15.4,65,,12.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.85,50,,9.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,16.11,
VZV AG BY DF,4000741,CDM,306,RC,87290,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,49.03,
MALARIA SMEAR,4000743,CDM,306,RC,87207,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,36.42,
FECAL LEUKOCYTES,4000745,CDM,309,RC,89055,HCPCS,Outpatient,,,30.9,15.45,,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,21.01,68,,16.808,Percent of Total Billed Charges,68% of Total Billed Charges,6.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,50,,12.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.06,21.01,
RSV AG NOSE QL,4000749,CDM,306,RC,87420,HCPCS,Outpatient,,,105.06,52.53,,68.29,65,,54.632,Percent of Total Billed Charges,65% of Total Billed Charges,71.44,68,,57.152,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.01,20,,16.808,Percent of Total Billed Charges,20% of Total Billed Charges,21.01,20,,16.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.01,20,,16.808,Percent of Total Billed Charges,20% of Total Billed Charges,21.01,20,,16.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.29,65,,54.632,Percent of Total Billed Charges,65% of Total Billed Charges,68.29,65,,54.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.53,50,,42.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.01,71.44,
KOH PREP VAGINAL,4000751,CDM,306,RC,87210,HCPCS,Outpatient,,,20.6,10.30,,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,14.01,68,,11.208,Percent of Total Billed Charges,68% of Total Billed Charges,6.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,4.12,20,,3.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,13.39,65,,10.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,50,,8.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,14.01,
HIV-1 GENOTYPE,4000753,CDM,306,RC,87901,HCPCS,Outpatient,,,386.25,193.13,,251.06,65,,200.848,Percent of Total Billed Charges,65% of Total Billed Charges,262.65,68,,210.12,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,20,,61.8,Percent of Total Billed Charges,20% of Total Billed Charges,77.25,20,,61.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,20,,61.8,Percent of Total Billed Charges,20% of Total Billed Charges,77.25,20,,61.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,251.06,65,,200.848,Percent of Total Billed Charges,65% of Total Billed Charges,251.06,65,,200.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.13,50,,154.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,262.65,
CHLAMYDIA PCR SWB/UR,4000761,CDM,306,RC,87491,HCPCS,Outpatient,,,132.87,66.44,,86.37,65,,69.096,Percent of Total Billed Charges,65% of Total Billed Charges,90.35,68,,72.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.57,20,,21.256,Percent of Total Billed Charges,20% of Total Billed Charges,26.57,20,,21.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.57,20,,21.256,Percent of Total Billed Charges,20% of Total Billed Charges,26.57,20,,21.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.37,65,,69.096,Percent of Total Billed Charges,65% of Total Billed Charges,86.37,65,,69.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.44,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.57,90.35,
FLU A AND B AG,4000763,CDM,306,RC,87804,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,28.02,
H. PYLORI AG (STOOL),4000765,CDM,306,RC,87338,HCPCS,Outpatient,,,94.76,47.38,,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,64.44,68,,51.552,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.38,50,,37.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,64.44,
MYCOPLASMA PCR SPUTU,4000767,CDM,306,RC,87109,HCPCS,Outpatient,,,163.77,81.89,,106.45,65,,85.16,Percent of Total Billed Charges,65% of Total Billed Charges,111.36,68,,89.088,Percent of Total Billed Charges,68% of Total Billed Charges,21.83,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,32.75,20,,26.2,Percent of Total Billed Charges,20% of Total Billed Charges,32.75,20,,26.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.75,20,,26.2,Percent of Total Billed Charges,20% of Total Billed Charges,32.75,20,,26.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.45,65,,85.16,Percent of Total Billed Charges,65% of Total Billed Charges,106.45,65,,85.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.89,50,,65.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.83,111.36,
HCG URINE QUALITATIVE,4000769,CDM,307,RC,81025,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,8.98,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,17.51,
.UA DIPSTICK CHARGE,4000771,CDM,301,RC,81003,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,3.18,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
URINE ACETONE,4000773,CDM,307,RC,81000,HCPCS,Outpatient,,,42.23,21.12,,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,28.72,68,,22.976,Percent of Total Billed Charges,68% of Total Billed Charges,4.49,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.12,50,,16.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.49,28.72,
URINALYSIS DIPSTICK PANEL,4000775,CDM,307,RC,81003,HCPCS,Outpatient,,,17,8.50,,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,11.56,68,,9.248,Percent of Total Billed Charges,68% of Total Billed Charges,3.18,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.18,11.56,
URINALYSIS DIPSTICK PANEL-CLINIC,4000776,CDM,307,RC,81003,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,3.18,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.18,3.18,
HCG SERUM QUALITATIVE,4000777,CDM,301,RC,84703,HCPCS,Outpatient,,,42.23,21.12,,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,28.72,68,,22.976,Percent of Total Billed Charges,68% of Total Billed Charges,10.66,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.12,50,,16.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,28.72,
BB ABO BLOOD TYPE,4000779,CDM,309,RC,86900,HCPCS,Outpatient,,,52.53,26.27,,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,35.72,68,,28.576,Percent of Total Billed Charges,68% of Total Billed Charges,4.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.27,50,,21.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,35.72,
BB RH TYPE,4000781,CDM,309,RC,86901,HCPCS,Outpatient,,,28.84,14.42,,18.75,65,,15,Percent of Total Billed Charges,65% of Total Billed Charges,19.61,68,,15.688,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,5.77,20,,4.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.75,65,,15,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,65,,15,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,50,,11.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,19.61,
BB DAT,4000783,CDM,309,RC,86880,HCPCS,Outpatient,,,52.53,26.27,,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,35.72,68,,28.576,Percent of Total Billed Charges,68% of Total Billed Charges,7.62,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.27,50,,21.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,35.72,
BB ANTIBODY SCREEN,4000785,CDM,309,RC,86885,HCPCS,Outpatient,,,95.79,47.90,,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,65.14,68,,52.112,Percent of Total Billed Charges,68% of Total Billed Charges,8.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.9,50,,38.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.12,65.14,
GLUT AC DCARB 65 ANTIBODY,4000786,CDM,301,RC,83519,HCPCS,Outpatient,,,146.78,73.39,,95.41,65,,76.328,Percent of Total Billed Charges,65% of Total Billed Charges,99.81,68,,79.848,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,29.36,20,,23.488,Percent of Total Billed Charges,20% of Total Billed Charges,29.36,20,,23.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,20,,23.488,Percent of Total Billed Charges,20% of Total Billed Charges,29.36,20,,23.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.41,65,,76.328,Percent of Total Billed Charges,65% of Total Billed Charges,95.41,65,,76.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.39,50,,58.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,99.81,
CSF ANALYSIS,4000787,CDM,309,RC,89050,HCPCS,Outpatient,,,84.46,42.23,,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,57.43,68,,45.944,Percent of Total Billed Charges,68% of Total Billed Charges,6.71,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,16.89,20,,13.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,54.9,65,,43.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.23,50,,33.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.71,57.43,
ER ONLY TOX SCREEN URINE,4000789,CDM,301,RC,80307,HCPCS,Outpatient,,,152.44,76.22,,99.09,65,,79.272,Percent of Total Billed Charges,65% of Total Billed Charges,103.66,68,,82.928,Percent of Total Billed Charges,68% of Total Billed Charges,19.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.09,65,,79.272,Percent of Total Billed Charges,65% of Total Billed Charges,99.09,65,,79.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.22,50,,60.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.58,103.66,
IA2 AUTOANTIBODIES,4000790,CDM,302,RC,86341,HCPCS,Outpatient,,,120.51,60.26,,78.33,65,,62.664,Percent of Total Billed Charges,65% of Total Billed Charges,81.95,68,,65.56,Percent of Total Billed Charges,68% of Total Billed Charges,28.08,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,24.1,20,,19.28,Percent of Total Billed Charges,20% of Total Billed Charges,24.1,20,,19.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,20,,19.28,Percent of Total Billed Charges,20% of Total Billed Charges,24.1,20,,19.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.33,65,,62.664,Percent of Total Billed Charges,65% of Total Billed Charges,78.33,65,,62.664,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,50,,48.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,81.95,
METHYLMALONIC ACID SERUM,4000792,CDM,301,RC,83921,HCPCS,Outpatient,,,200.85,100.43,,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,136.58,68,,109.264,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,50,,80.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,136.58,
CRYSTALS FLUID,4000793,CDM,309,RC,89060,HCPCS,Outpatient,,,70.04,35.02,,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,47.63,68,,38.104,Percent of Total Billed Charges,68% of Total Billed Charges,10.15,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,14.01,20,,11.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,65,,36.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,50,,28.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.15,47.63,
METHYLMALONIC ACID URINE,4000794,CDM,301,RC,83921,HCPCS,Outpatient,,,200.85,100.43,,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,136.58,68,,109.264,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,40.17,20,,32.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,130.55,65,,104.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,50,,80.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,136.58,
ANTIBODY IDENTIFY,4000795,CDM,309,RC,86870,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.85,50,,78.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,133.08,
INPATIENT COVID-19,4000796,CDM,302,RC,87635,HCPCS,Outpatient,,,268.51,134.26,,174.53,65,,139.624,Percent of Total Billed Charges,65% of Total Billed Charges,182.59,68,,146.072,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.7,20,,42.96,Percent of Total Billed Charges,20% of Total Billed Charges,53.7,20,,42.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.7,20,,42.96,Percent of Total Billed Charges,20% of Total Billed Charges,53.7,20,,42.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.53,65,,139.624,Percent of Total Billed Charges,65% of Total Billed Charges,174.53,65,,139.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.26,50,,107.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.7,182.59,
PSA SCREEN,4000797,CDM,309,RC,G0103,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
RESPIRATORY PATHOGEN PANEL,4000798,CDM,306,RC,87633,HCPCS,Outpatient,,,1057.85,528.93,,687.6,65,,550.08,Percent of Total Billed Charges,65% of Total Billed Charges,719.34,68,,575.472,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.57,20,,169.256,Percent of Total Billed Charges,20% of Total Billed Charges,211.57,20,,169.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.57,20,,169.256,Percent of Total Billed Charges,20% of Total Billed Charges,211.57,20,,169.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,687.6,65,,550.08,Percent of Total Billed Charges,65% of Total Billed Charges,687.6,65,,550.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,528.93,50,,423.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.57,719.34,
AGN/SPECIAL TYPING,4000799,CDM,309,RC,86902,HCPCS,Outpatient,,,95.79,47.90,,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,65.14,68,,52.112,Percent of Total Billed Charges,68% of Total Billed Charges,8.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.9,50,,38.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.37,65.14,
CELL COUNT BODY FLD,4000801,CDM,309,RC,89051,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,7.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.82,28.02,
BB POOLING OF PH/OTHER,4000803,CDM,309,RC,86965,HCPCS,Outpatient,,,95.79,47.90,,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,65.14,68,,52.112,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.9,50,,38.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,65.14,
BB THAWING FFP EA UNIT,4000805,CDM,309,RC,86927,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.85,50,,78.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,133.08,
CYTOPATHOLOGY,4000823,CDM,310,RC,88108,HCPCS,Outpatient,,,95.79,47.90,,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,65.14,68,,52.112,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.9,50,,38.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,65.14,
URINE CYTOLOGY,4000825,CDM,310,RC,88108,HCPCS,Outpatient,,,110.21,55.11,,71.64,65,,57.312,Percent of Total Billed Charges,65% of Total Billed Charges,74.94,68,,59.952,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.04,20,,17.632,Percent of Total Billed Charges,20% of Total Billed Charges,22.04,20,,17.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.04,20,,17.632,Percent of Total Billed Charges,20% of Total Billed Charges,22.04,20,,17.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.64,65,,57.312,Percent of Total Billed Charges,65% of Total Billed Charges,71.64,65,,57.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.11,50,,44.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.04,74.94,
SPECIAL STAINS GROII,4000827,CDM,310,RC,88313,HCPCS,Outpatient,,,62.83,31.42,,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,42.72,68,,34.176,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.42,50,,25.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,42.72,
IMMUNOCHEM EA AB,4000829,CDM,310,RC,88342,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.85,50,,78.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,133.08,
IMMUNOCYTOCHEM AB,4000833,CDM,310,RC,88342,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.85,50,,78.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,133.08,
TOUCH PREP,4000837,CDM,311,RC,88161,HCPCS,Outpatient,,,79.31,39.66,,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,53.93,68,,43.144,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,50,,31.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.86,53.93,
CYTOLOGY,4000839,CDM,311,RC,88112,HCPCS,Outpatient,,,95.79,47.90,,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,65.14,68,,52.112,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.9,50,,38.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,65.14,
BB ADDITIONAL UNIT CROSSMATCH,4000843,CDM,309,RC,86922,HCPCS,Outpatient,,,97.85,48.93,,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,66.54,68,,53.232,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.93,50,,39.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,66.54,
BB PLATELETS-EACH UNIT,4000845,CDM,384,RC,P9019,HCPCS,Outpatient,,,60.77,30.39,,39.5,65,,31.6,Percent of Total Billed Charges,65% of Total Billed Charges,41.32,68,,33.056,Percent of Total Billed Charges,68% of Total Billed Charges,44,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,12.15,20,,9.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.5,65,,31.6,Percent of Total Billed Charges,65% of Total Billed Charges,39.5,65,,31.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.15,53.67,
BB APHERESIS,4000847,CDM,384,RC,P9034,HCPCS,Outpatient,,,525.3,262.65,,341.45,65,,273.16,Percent of Total Billed Charges,65% of Total Billed Charges,357.2,68,,285.76,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.06,20,,84.048,Percent of Total Billed Charges,20% of Total Billed Charges,105.06,20,,84.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.06,20,,84.048,Percent of Total Billed Charges,20% of Total Billed Charges,105.06,20,,84.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.45,65,,273.16,Percent of Total Billed Charges,65% of Total Billed Charges,341.45,65,,273.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,357.2,
THERAPEUTIC PHLEBOTOMY,4000851,CDM,940,RC,99195,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,74,
BB BLD TYPE RBC AG NOT A/R,4000855,CDM,309,RC,86905,HCPCS,Outpatient,,,95.79,47.90,,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,65.14,68,,52.112,Percent of Total Billed Charges,68% of Total Billed Charges,5.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,19.16,20,,15.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,62.26,65,,49.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.9,50,,38.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.43,65.14,
CATECHOLAMINES FRACTION,4000857,CDM,301,RC,82384,HCPCS,Outpatient,,,36.05,18.03,,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,24.51,68,,19.608,Percent of Total Billed Charges,68% of Total Billed Charges,32.92,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,50,,14.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,32.92,
FAT/LIPIDS FECES QUAL,4000859,CDM,301,RC,82705,HCPCS,Outpatient,,,10.3,5.15,,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,7,68,,5.6,Percent of Total Billed Charges,68% of Total Billed Charges,7.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,7.23,
GLUCOSE BLOOD REAG STRIP,4000861,CDM,301,RC,82948,HCPCS,Outpatient,,,10.3,5.15,,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,7,68,,5.6,Percent of Total Billed Charges,68% of Total Billed Charges,4.49,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,7,
GROWTH HORMONE HUMAN,4000863,CDM,301,RC,83003,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,23.66,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,23.66,
THYROXINE TOTAL,4000865,CDM,301,RC,84436,HCPCS,Outpatient,,,12.36,6.18,,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.4,68,,6.72,Percent of Total Billed Charges,68% of Total Billed Charges,9.76,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,2.47,20,,1.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,8.03,65,,6.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,50,,4.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,9.76,
DRUG SCREEN-PREEMPLOYMENT ONLY,4000869,CDM,301,RC,80305,HCPCS,Outpatient,,,20,10.00,,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,19.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,19.58,
IMMUNFIX E-PHOR/URINE/CSF,4000871,CDM,302,RC,86335,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
BB INVEST TRANSFUS REACTION,4000873,CDM,302,RC,86078,HCPCS,Outpatient,,,94.76,47.38,,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,64.44,68,,51.552,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,18.95,20,,15.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,61.59,65,,49.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.38,50,,37.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.95,64.44,
BACT CULT:QUAN AEROBIC,4000875,CDM,306,RC,87071,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
BCT CULT-QUAN ANAEROBIC,4000877,CDM,306,RC,87073,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
C DIF STL QL CULT,4000879,CDM,306,RC,87493,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
GTT 1 HOUR CHARGE,4000881,CDM,301,RC,82951,HCPCS,Outpatient,,,42.23,21.12,,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,28.72,68,,22.976,Percent of Total Billed Charges,68% of Total Billed Charges,16.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.12,50,,16.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,28.72,
CK W/O MMB,4000883,CDM,301,RC,82550,HCPCS,Outpatient,,,22.66,11.33,,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,15.41,68,,12.328,Percent of Total Billed Charges,68% of Total Billed Charges,9.25,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,15.41,
CATECHOLAMINES BLOOD,4000885,CDM,301,RC,82383,HCPCS,Outpatient,,,26.78,13.39,,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,18.21,68,,14.568,Percent of Total Billed Charges,68% of Total Billed Charges,35.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,5.36,20,,4.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,17.41,65,,13.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,50,,10.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,35.57,
PREALBUMIN,4000887,CDM,301,RC,84134,HCPCS,Outpatient,,,50.68,25.34,,32.94,65,,26.352,Percent of Total Billed Charges,65% of Total Billed Charges,34.46,68,,27.568,Percent of Total Billed Charges,68% of Total Billed Charges,20.7,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.14,20,,8.112,Percent of Total Billed Charges,20% of Total Billed Charges,10.14,20,,8.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.14,20,,8.112,Percent of Total Billed Charges,20% of Total Billed Charges,10.14,20,,8.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.94,65,,26.352,Percent of Total Billed Charges,65% of Total Billed Charges,32.94,65,,26.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.34,50,,20.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.14,34.46,
"PROSTAGLANDIN, E2",4000889,CDM,301,RC,84150,HCPCS,Outpatient,,,31.93,15.97,,20.75,65,,16.6,Percent of Total Billed Charges,65% of Total Billed Charges,21.71,68,,17.368,Percent of Total Billed Charges,68% of Total Billed Charges,35.43,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.75,65,,16.6,Percent of Total Billed Charges,65% of Total Billed Charges,20.75,65,,16.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.97,50,,12.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,35.43,
RSVAG BY IF,4000891,CDM,306,RC,87280,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
.URINALYSIS - MICRO ONLY,4000893,CDM,307,RC,81015,HCPCS,Outpatient,,,4.12,2.06,,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.8,68,,2.24,Percent of Total Billed Charges,68% of Total Billed Charges,3.98,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,0.82,20,,0.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,2.68,65,,2.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,3.98,
LIPID/REFLEX,4000896,CDM,301,RC,80061,HCPCS,Outpatient,,,124.63,62.32,,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,84.75,68,,67.8,Percent of Total Billed Charges,68% of Total Billed Charges,19.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.32,50,,49.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.01,84.75,
BACTERIA URTH CULT,4000899,CDM,306,RC,87086,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,11.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.46,42.02,
BACTERIA BLD CULT,4000901,CDM,306,RC,87040,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,14.65,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.65,63.04,
ANAEROBIC CULTURE QUEST,4000903,CDM,306,RC,87070,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
ED COVID-19,4000904,CDM,306,RC,87635,HCPCS,Outpatient,,,498.39,249.20,,323.95,65,,259.16,Percent of Total Billed Charges,65% of Total Billed Charges,338.91,68,,271.128,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.68,20,,79.744,Percent of Total Billed Charges,20% of Total Billed Charges,99.68,20,,79.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.68,20,,79.744,Percent of Total Billed Charges,20% of Total Billed Charges,99.68,20,,79.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,323.95,65,,259.16,Percent of Total Billed Charges,65% of Total Billed Charges,323.95,65,,259.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.2,50,,199.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.68,338.91,
THROAT CULTURE QUEST,4000905,CDM,306,RC,87081,HCPCS,Outpatient,,,42.23,21.12,,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,28.72,68,,22.976,Percent of Total Billed Charges,68% of Total Billed Charges,9.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.12,50,,16.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,28.72,
QUEST SARS-CoV-2 COVID-19,4000906,CDM,306,RC,87635,HCPCS,Outpatient,,,893.77,446.89,,580.95,65,,464.76,Percent of Total Billed Charges,65% of Total Billed Charges,607.76,68,,486.208,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.75,20,,143,Percent of Total Billed Charges,20% of Total Billed Charges,178.75,20,,143,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.75,20,,143,Percent of Total Billed Charges,20% of Total Billed Charges,178.75,20,,143,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,580.95,65,,464.76,Percent of Total Billed Charges,65% of Total Billed Charges,580.95,65,,464.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.89,50,,357.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.75,607.76,
VIRAL CULTURE GENERAL,4000907,CDM,306,RC,87252,HCPCS,Outpatient,,,226.6,113.30,,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,154.09,68,,123.272,Percent of Total Billed Charges,68% of Total Billed Charges,37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.3,50,,90.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,154.09,
SENSITIVITY SO,4000909,CDM,306,RC,87184,HCPCS,Outpatient,,,52.53,26.27,,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,35.72,68,,28.576,Percent of Total Billed Charges,68% of Total Billed Charges,9.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,10.51,20,,8.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,34.14,65,,27.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.27,50,,21.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.79,35.72,
THYROGLOBULIN AB,4000911,CDM,302,RC,86800,HCPCS,Outpatient,,,182.31,91.16,,118.5,65,,94.8,Percent of Total Billed Charges,65% of Total Billed Charges,123.97,68,,99.176,Percent of Total Billed Charges,68% of Total Billed Charges,22.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,36.46,20,,29.168,Percent of Total Billed Charges,20% of Total Billed Charges,36.46,20,,29.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.46,20,,29.168,Percent of Total Billed Charges,20% of Total Billed Charges,36.46,20,,29.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.5,65,,94.8,Percent of Total Billed Charges,65% of Total Billed Charges,118.5,65,,94.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.16,50,,72.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.57,123.97,
THYROPEROXIDASE AB,4000913,CDM,302,RC,86376,HCPCS,Outpatient,,,190.55,95.28,,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,129.57,68,,103.656,Percent of Total Billed Charges,68% of Total Billed Charges,20.65,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,38.11,20,,30.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,123.86,65,,99.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.28,50,,76.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.65,129.57,
.INFLUENZA A,4000914,CDM,306,RC,87804,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,28.02,
.INFLUENZA B,4000915,CDM,306,RC,87804,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,28.02,
PROCALCITONIN,4000918,CDM,301,RC,84145,HCPCS,Outpatient,,,353.81,176.91,,229.98,65,,183.984,Percent of Total Billed Charges,65% of Total Billed Charges,240.59,68,,192.472,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.76,20,,56.608,Percent of Total Billed Charges,20% of Total Billed Charges,70.76,20,,56.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.76,20,,56.608,Percent of Total Billed Charges,20% of Total Billed Charges,70.76,20,,56.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.98,65,,183.984,Percent of Total Billed Charges,65% of Total Billed Charges,229.98,65,,183.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.91,50,,141.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.76,240.59,
CORTISOL FREE 24 HR URINE,4000919,CDM,301,RC,82530,HCPCS,Outpatient,,,135.96,67.98,,88.37,65,,70.696,Percent of Total Billed Charges,65% of Total Billed Charges,92.45,68,,73.96,Percent of Total Billed Charges,68% of Total Billed Charges,23.72,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,27.19,20,,21.752,Percent of Total Billed Charges,20% of Total Billed Charges,27.19,20,,21.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.19,20,,21.752,Percent of Total Billed Charges,20% of Total Billed Charges,27.19,20,,21.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.37,65,,70.696,Percent of Total Billed Charges,65% of Total Billed Charges,88.37,65,,70.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.98,50,,54.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.72,92.45,
INSULIN GROWTH FACTOR - 1,4000920,CDM,301,RC,84305,HCPCS,Outpatient,,,207.03,103.52,,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,140.78,68,,112.624,Percent of Total Billed Charges,68% of Total Billed Charges,27.25,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.52,50,,82.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.25,140.78,
PERIPHERAL SMEAR,4000921,CDM,305,RC,85060,HCPCS,Outpatient,,,30.9,15.45,,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,21.01,68,,16.808,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,50,,12.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,21.01,
REFERENCE DRAW FEE QUEST/LABCORP,4000922,CDM,300,RC,36415,HCPCS,Outpatient,,,12,6.00,,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,8.16,68,,6.528,Percent of Total Billed Charges,68% of Total Billed Charges,3,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,8.16,
RSV AG,4000923,CDM,306,RC,87807,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,36.42,
C-REACTIVE PROTEIN (CRP),4000924,CDM,302,RC,86140,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,7.34,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,56.03,
PH BODY FLUID,4000925,CDM,301,RC,83986,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,5.08,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.08,42.02,
BARTONELLA HENSELAE AB. IgG,4000926,CDM,302,RC,86611,HCPCS,Outpatient,,,76.74,38.37,,49.88,65,,39.904,Percent of Total Billed Charges,65% of Total Billed Charges,52.18,68,,41.744,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.88,65,,39.904,Percent of Total Billed Charges,65% of Total Billed Charges,49.88,65,,39.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.37,50,,30.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,52.18,
BARTONELLA HENSELAE AB.IgM,4000927,CDM,302,RC,86611,HCPCS,Outpatient,,,76.74,38.37,,49.88,65,,39.904,Percent of Total Billed Charges,65% of Total Billed Charges,52.18,68,,41.744,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,15.35,20,,12.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.88,65,,39.904,Percent of Total Billed Charges,65% of Total Billed Charges,49.88,65,,39.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.37,50,,30.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,52.18,
LIVER FIBROSIS,4000928,CDM,301,RC,81596,HCPCS,Outpatient,,,309.31,154.66,,201.05,65,,160.84,Percent of Total Billed Charges,65% of Total Billed Charges,210.33,68,,168.264,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.86,20,,49.488,Percent of Total Billed Charges,20% of Total Billed Charges,61.86,20,,49.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.86,20,,49.488,Percent of Total Billed Charges,20% of Total Billed Charges,61.86,20,,49.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.05,65,,160.84,Percent of Total Billed Charges,65% of Total Billed Charges,201.05,65,,160.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.66,50,,123.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.86,210.33,
BB RED CELL UNIT,4000929,CDM,390,RC,P9016,HCPCS,Outpatient,,,429,214.50,,278.85,65,,223.08,Percent of Total Billed Charges,65% of Total Billed Charges,291.72,68,,233.376,Percent of Total Billed Charges,68% of Total Billed Charges,104,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,85.8,20,,68.64,Percent of Total Billed Charges,20% of Total Billed Charges,85.8,20,,68.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.8,20,,68.64,Percent of Total Billed Charges,20% of Total Billed Charges,85.8,20,,68.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.85,65,,223.08,Percent of Total Billed Charges,65% of Total Billed Charges,278.85,65,,223.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,291.72,
RAPID COVID 19 ANTIGEN,4000930,CDM,302,RC,87426,HCPCS,Outpatient,,,166.86,83.43,,108.46,65,,86.768,Percent of Total Billed Charges,65% of Total Billed Charges,113.46,68,,90.768,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.37,20,,26.696,Percent of Total Billed Charges,20% of Total Billed Charges,33.37,20,,26.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.37,20,,26.696,Percent of Total Billed Charges,20% of Total Billed Charges,33.37,20,,26.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.46,65,,86.768,Percent of Total Billed Charges,65% of Total Billed Charges,108.46,65,,86.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.43,50,,66.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.37,113.46,
RAPID RSV RNA,4000931,CDM,306,RC,87634,HCPCS,Outpatient,,,105.3,52.65,,68.45,65,,54.76,Percent of Total Billed Charges,65% of Total Billed Charges,71.6,68,,57.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.06,20,,16.848,Percent of Total Billed Charges,20% of Total Billed Charges,21.06,20,,16.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.06,20,,16.848,Percent of Total Billed Charges,20% of Total Billed Charges,21.06,20,,16.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.45,65,,54.76,Percent of Total Billed Charges,65% of Total Billed Charges,68.45,65,,54.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.65,50,,42.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.06,71.6,
CYCLIC CITTRULLINATED PEPTIDE(CCP)ANTIBO,4000932,CDM,302,RC,86200,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,63.04,
DNA (DS) ANTIBODY,4000933,CDM,302,RC,86225,HCPCS,Outpatient,,,56.65,28.33,,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,38.52,68,,30.816,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.33,50,,22.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,38.52,
JO-1 ANTIBODY,4000934,CDM,302,RC,86235,HCPCS,Outpatient,,,49.4,24.70,,32.11,65,,25.688,Percent of Total Billed Charges,65% of Total Billed Charges,33.59,68,,26.872,Percent of Total Billed Charges,68% of Total Billed Charges,25.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.88,20,,7.904,Percent of Total Billed Charges,20% of Total Billed Charges,9.88,20,,7.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.88,20,,7.904,Percent of Total Billed Charges,20% of Total Billed Charges,9.88,20,,7.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.11,65,,25.688,Percent of Total Billed Charges,65% of Total Billed Charges,32.11,65,,25.688,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.7,50,,19.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.88,33.59,
SCLERODERMA ANTIBODY (SCL-70),4000935,CDM,302,RC,86235,HCPCS,Outpatient,,,13.21,6.61,,8.59,65,,6.872,Percent of Total Billed Charges,65% of Total Billed Charges,8.98,68,,7.184,Percent of Total Billed Charges,68% of Total Billed Charges,25.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,2.64,20,,2.112,Percent of Total Billed Charges,20% of Total Billed Charges,2.64,20,,2.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.64,20,,2.112,Percent of Total Billed Charges,20% of Total Billed Charges,2.64,20,,2.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.59,65,,6.872,Percent of Total Billed Charges,65% of Total Billed Charges,8.59,65,,6.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.61,50,,5.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.64,25.45,
21- HYDROXYLASE ANTIBODY,4000936,CDM,301,RC,83516,HCPCS,Outpatient,,,110.21,55.11,,71.64,65,,57.312,Percent of Total Billed Charges,65% of Total Billed Charges,74.94,68,,59.952,Percent of Total Billed Charges,68% of Total Billed Charges,16.38,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,22.04,20,,17.632,Percent of Total Billed Charges,20% of Total Billed Charges,22.04,20,,17.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.04,20,,17.632,Percent of Total Billed Charges,20% of Total Billed Charges,22.04,20,,17.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.64,65,,57.312,Percent of Total Billed Charges,65% of Total Billed Charges,71.64,65,,57.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.11,50,,44.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.38,74.94,
PNEUMOCYSTIS JIROVECII (P. CARINII) DFA,4000937,CDM,306,RC,87281,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.26,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
QUANTIFERON?-TB GOLD PLUS,4000938,CDM,302,RC,86480,HCPCS,Outpatient,,,56.65,28.33,,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,38.52,68,,30.816,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,36.82,65,,29.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.33,50,,22.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,38.52,
TSH WITH REFLEX TO FREE T4 RL,4000939,CDM,300,RC,84443,HCPCS,Outpatient,,,14.42,7.21,,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,9.81,68,,7.848,Percent of Total Billed Charges,68% of Total Billed Charges,23.84,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,2.88,20,,2.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,9.37,65,,7.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,50,,5.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,23.84,
HEMOGLOBINOPATHY EVALUATION,4000941,CDM,301,RC,83020,HCPCS,Outpatient,,,77.66,38.83,,50.48,65,,40.384,Percent of Total Billed Charges,65% of Total Billed Charges,52.81,68,,42.248,Percent of Total Billed Charges,68% of Total Billed Charges,18.28,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.53,20,,12.424,Percent of Total Billed Charges,20% of Total Billed Charges,15.53,20,,12.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,20,,12.424,Percent of Total Billed Charges,20% of Total Billed Charges,15.53,20,,12.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.48,65,,40.384,Percent of Total Billed Charges,65% of Total Billed Charges,50.48,65,,40.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.83,50,,31.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,52.81,
MISC SENDOUT QUEST,4000942,CDM,306,RC,87086,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,11.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.46,42.02,
ADMIN HEP B VACCINE,4000988,CDM,771,RC,G0010,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,85,
LIPIDS BODY FLUID,4010017,CDM,301,RC,80061,HCPCS,Outpatient,,,124.63,62.32,,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,84.75,68,,67.8,Percent of Total Billed Charges,68% of Total Billed Charges,19.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.32,50,,49.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.01,84.75,
OCCULT BLOOD CARD 1,4010024,CDM,301,RC,82272,HCPCS,Outpatient,,,22.66,11.33,,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,15.41,68,,12.328,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,15.41,
CK-MB,4010025,CDM,301,RC,82553,HCPCS,Outpatient,,,62.32,31.16,,40.51,65,,32.408,Percent of Total Billed Charges,65% of Total Billed Charges,42.38,68,,33.904,Percent of Total Billed Charges,68% of Total Billed Charges,12.86,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.46,20,,9.968,Percent of Total Billed Charges,20% of Total Billed Charges,12.46,20,,9.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.46,20,,9.968,Percent of Total Billed Charges,20% of Total Billed Charges,12.46,20,,9.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.51,65,,32.408,Percent of Total Billed Charges,65% of Total Billed Charges,40.51,65,,32.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.16,50,,24.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.46,42.38,
AMYLASE PRT-CCNC,4010031,CDM,301,RC,82150,HCPCS,Outpatient,,,28.33,14.17,,18.41,65,,14.728,Percent of Total Billed Charges,65% of Total Billed Charges,19.26,68,,15.408,Percent of Total Billed Charges,68% of Total Billed Charges,9.2,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.67,20,,4.536,Percent of Total Billed Charges,20% of Total Billed Charges,5.67,20,,4.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,20,,4.536,Percent of Total Billed Charges,20% of Total Billed Charges,5.67,20,,4.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.41,65,,14.728,Percent of Total Billed Charges,65% of Total Billed Charges,18.41,65,,14.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,50,,11.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,19.26,
CREATININE W/GFR,4010047,CDM,301,RC,82565,HCPCS,Outpatient,,,30.9,15.45,,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,21.01,68,,16.808,Percent of Total Billed Charges,68% of Total Billed Charges,7.27,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,50,,12.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,21.01,
GLUCOSE 1-HR POSTPRANDIAL-SERUM,4010053,CDM,301,RC,82947,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,5.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,17.51,
LDH BODY FLUID,4010059,CDM,301,RC,83615,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,8.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,17.51,
BLOOD GAS PANEL,4010067,CDM,301,RC,82803,HCPCS,Outpatient,,,298.7,149.35,,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,203.12,68,,162.496,Percent of Total Billed Charges,68% of Total Billed Charges,27.47,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.35,50,,119.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.47,203.12,
MAGNESIUM SERUM REF LAB,4010077,CDM,301,RC,83735,HCPCS,Outpatient,,,51.5,25.75,,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,68,,28.016,Percent of Total Billed Charges,68% of Total Billed Charges,9.51,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,10.3,20,,8.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,33.48,65,,26.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.75,50,,20.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.51,35.02,
TOTAL CHOLESTEROL FASTING-SERUM,4010087,CDM,301,RC,82465,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,4.69,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,17.51,
DIGOXIN LEVEL REF LAB,4010097,CDM,301,RC,80162,HCPCS,Outpatient,,,73.65,36.83,,47.87,65,,38.296,Percent of Total Billed Charges,65% of Total Billed Charges,50.08,68,,40.064,Percent of Total Billed Charges,68% of Total Billed Charges,18.85,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.73,20,,11.784,Percent of Total Billed Charges,20% of Total Billed Charges,14.73,20,,11.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,20,,11.784,Percent of Total Billed Charges,20% of Total Billed Charges,14.73,20,,11.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.87,65,,38.296,Percent of Total Billed Charges,65% of Total Billed Charges,47.87,65,,38.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,50,,29.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,50.08,
FOLATE (FOLIC ACID) REF LAB,4010103,CDM,301,RC,82746,HCPCS,Outpatient,,,71.38,35.69,,46.4,65,,37.12,Percent of Total Billed Charges,65% of Total Billed Charges,48.54,68,,38.832,Percent of Total Billed Charges,68% of Total Billed Charges,20.87,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.28,20,,11.424,Percent of Total Billed Charges,20% of Total Billed Charges,14.28,20,,11.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.28,20,,11.424,Percent of Total Billed Charges,20% of Total Billed Charges,14.28,20,,11.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.4,65,,37.12,Percent of Total Billed Charges,65% of Total Billed Charges,46.4,65,,37.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.69,50,,28.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.28,48.54,
IRON REF LAB,4010109,CDM,301,RC,83540,HCPCS,Outpatient,,,33.99,17.00,,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,23.11,68,,18.488,Percent of Total Billed Charges,68% of Total Billed Charges,9.2,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,22.09,65,,17.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,23.11,
THYROID STIMULATING HORMONE REF LAB,4010119,CDM,301,RC,84443,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,23.84,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,63.04,
T4 FREE-SERUM,4010121,CDM,301,RC,84439,HCPCS,Outpatient,,,79.31,39.66,,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,53.93,68,,43.144,Percent of Total Billed Charges,68% of Total Billed Charges,12.8,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,15.86,20,,12.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,51.55,65,,41.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,50,,31.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,53.93,
CEA SERUM,4010129,CDM,301,RC,82378,HCPCS,Outpatient,,,87.55,43.78,,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,59.53,68,,47.624,Percent of Total Billed Charges,68% of Total Billed Charges,26.93,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,17.51,20,,14.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,56.91,65,,45.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.78,50,,35.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.51,59.53,
LEAD (PEDIATRIC),4010135,CDM,301,RC,83655,HCPCS,Outpatient,,,62.83,31.42,,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,42.72,68,,34.176,Percent of Total Billed Charges,68% of Total Billed Charges,17.18,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,12.57,20,,10.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,40.84,65,,32.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.42,50,,25.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,42.72,
HGB A1C REF LAB,4010159,CDM,301,RC,83036,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,13.78,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.78,52.53,
LIPASE REF LAB,4010163,CDM,301,RC,83690,HCPCS,Outpatient,,,39.66,19.83,,25.78,65,,20.624,Percent of Total Billed Charges,65% of Total Billed Charges,26.97,68,,21.576,Percent of Total Billed Charges,68% of Total Billed Charges,9.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,7.93,20,,6.344,Percent of Total Billed Charges,20% of Total Billed Charges,7.93,20,,6.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.93,20,,6.344,Percent of Total Billed Charges,20% of Total Billed Charges,7.93,20,,6.344,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.78,65,,20.624,Percent of Total Billed Charges,65% of Total Billed Charges,25.78,65,,20.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.83,50,,15.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.93,26.97,
PARATHYROID HORMONE INTACT (PTH),4010167,CDM,301,RC,83970,HCPCS,Outpatient,,,307.97,153.99,,200.18,65,,160.144,Percent of Total Billed Charges,65% of Total Billed Charges,209.42,68,,167.536,Percent of Total Billed Charges,68% of Total Billed Charges,58.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,61.59,20,,49.272,Percent of Total Billed Charges,20% of Total Billed Charges,61.59,20,,49.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,20,,49.272,Percent of Total Billed Charges,20% of Total Billed Charges,61.59,20,,49.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.18,65,,160.144,Percent of Total Billed Charges,65% of Total Billed Charges,200.18,65,,160.144,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.99,50,,123.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.58,209.42,
FERRITIN-SERUM REF LAB,4010173,CDM,301,RC,82728,HCPCS,Outpatient,,,82.4,41.20,,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,56.03,68,,44.824,Percent of Total Billed Charges,68% of Total Billed Charges,19.33,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,16.48,20,,13.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,53.56,65,,42.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,50,,32.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.48,56.03,
GENTAMYCIN LEVEL,4010189,CDM,301,RC,80170,HCPCS,Outpatient,,,75.19,37.60,,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,51.13,68,,40.904,Percent of Total Billed Charges,68% of Total Billed Charges,23.26,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.6,50,,30.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.04,51.13,
VANCOMYCIN LEVEL REF LAB,4010263,CDM,301,RC,80202,HCPCS,Outpatient,,,133.9,66.95,,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,68,,72.84,Percent of Total Billed Charges,68% of Total Billed Charges,19.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,50,,53.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.23,91.05,
VITAMIN B12-SERUM REF LAB,4010307,CDM,301,RC,82607,HCPCS,Outpatient,,,72.1,36.05,,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,49.03,68,,39.224,Percent of Total Billed Charges,68% of Total Billed Charges,21.39,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,14.42,20,,11.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,46.87,65,,37.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,50,,28.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.42,49.03,
SODIUM UR 24 HOUR,4010311,CDM,301,RC,84300,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,6.9,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,36.42,
URINE POTASSIUM W/CREAT,4010315,CDM,301,RC,84133,HCPCS,Outpatient,,,53.56,26.78,,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,36.42,68,,29.136,Percent of Total Billed Charges,68% of Total Billed Charges,6.1,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,10.71,20,,8.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,34.81,65,,27.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,50,,21.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.1,36.42,
MYOGLOBIN-SERUM,4010335,CDM,301,RC,83874,HCPCS,Outpatient,,,86.52,43.26,,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,58.83,68,,47.064,Percent of Total Billed Charges,68% of Total Billed Charges,18.32,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,17.3,20,,13.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,56.24,65,,44.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.26,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,58.83,
AFP-TUMOR MARKER,4010427,CDM,301,RC,82105,HCPCS,Outpatient,,,47.38,23.69,,30.8,65,,24.64,Percent of Total Billed Charges,65% of Total Billed Charges,32.22,68,,25.776,Percent of Total Billed Charges,68% of Total Billed Charges,23.81,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.8,65,,24.64,Percent of Total Billed Charges,65% of Total Billed Charges,30.8,65,,24.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.69,50,,18.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,32.22,
VITAMIN D 25-OH TOTAL IA REF LAB,4010459,CDM,301,RC,82306,HCPCS,Outpatient,,,100.94,50.47,,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,68.64,68,,54.912,Percent of Total Billed Charges,68% of Total Billed Charges,42.01,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,20.19,20,,16.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,65.61,65,,52.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.47,50,,40.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,68.64,
RHEUMATOID FACTOR,4010489,CDM,302,RC,86431,HCPCS,Outpatient,,,48.41,24.21,,31.47,65,,25.176,Percent of Total Billed Charges,65% of Total Billed Charges,32.92,68,,26.336,Percent of Total Billed Charges,68% of Total Billed Charges,8.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.68,20,,7.744,Percent of Total Billed Charges,20% of Total Billed Charges,9.68,20,,7.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.68,20,,7.744,Percent of Total Billed Charges,20% of Total Billed Charges,9.68,20,,7.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.47,65,,25.176,Percent of Total Billed Charges,65% of Total Billed Charges,31.47,65,,25.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,50,,19.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.06,32.92,
HSV1 IGM SER QL IF,4010549,CDM,302,RC,86695,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,18.72,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
TREPONEMA PALLIDUM AB AGGLUTINATION,4010587,CDM,302,RC,86780,HCPCS,Outpatient,,,132.08,66.04,,85.85,65,,68.68,Percent of Total Billed Charges,65% of Total Billed Charges,89.81,68,,71.848,Percent of Total Billed Charges,68% of Total Billed Charges,18.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.42,20,,21.136,Percent of Total Billed Charges,20% of Total Billed Charges,26.42,20,,21.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.42,20,,21.136,Percent of Total Billed Charges,20% of Total Billed Charges,26.42,20,,21.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.85,65,,68.68,Percent of Total Billed Charges,65% of Total Billed Charges,85.85,65,,68.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.04,50,,52.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.79,89.81,
LACTIC ACID REF LAB,4010598,CDM,302,RC,83605,HCPCS,Outpatient,,,96.82,48.41,,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,65.84,68,,52.672,Percent of Total Billed Charges,68% of Total Billed Charges,15.15,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,19.36,20,,15.488,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,62.93,65,,50.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.41,50,,38.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.15,65.84,
HSV2 IGM SER QL IF,4010617,CDM,302,RC,86696,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
PT/INR,4010649,CDM,305,RC,85610,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,5.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.58,42.02,
CBC (HEMOGRAM),4010661,CDM,305,RC,85027,HCPCS,Outpatient,,,28.33,14.17,,18.41,65,,14.728,Percent of Total Billed Charges,65% of Total Billed Charges,19.26,68,,15.408,Percent of Total Billed Charges,68% of Total Billed Charges,9.19,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.67,20,,4.536,Percent of Total Billed Charges,20% of Total Billed Charges,5.67,20,,4.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,20,,4.536,Percent of Total Billed Charges,20% of Total Billed Charges,5.67,20,,4.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.41,65,,14.728,Percent of Total Billed Charges,65% of Total Billed Charges,18.41,65,,14.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,50,,11.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,19.26,
ANC PROFILE,4010662,CDM,305,RC,85048,HCPCS,Outpatient,,,24.72,12.36,,16.07,65,,12.856,Percent of Total Billed Charges,65% of Total Billed Charges,16.81,68,,13.448,Percent of Total Billed Charges,68% of Total Billed Charges,3.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,4.94,20,,3.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,65,,12.856,Percent of Total Billed Charges,65% of Total Billed Charges,16.07,65,,12.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,16.81,
ROUTINE CULTURE-URINE,4010691,CDM,306,RC,87086,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,11.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.46,42.02,
THROAT CULTURE,4010701,CDM,306,RC,87081,HCPCS,Outpatient,,,42.23,21.12,,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,28.72,68,,22.976,Percent of Total Billed Charges,68% of Total Billed Charges,9.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,8.45,20,,6.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,27.45,65,,21.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.12,50,,16.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.45,28.72,
ENT/OTHER CULTURE,4010705,CDM,306,RC,87070,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
UA MICRO CHARGE,4010771,CDM,301,RC,81001,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,4.49,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
CELL COUNT BODY FLUID,4010801,CDM,309,RC,89051,HCPCS,Outpatient,,,41.2,20.60,,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,28.02,68,,22.416,Percent of Total Billed Charges,68% of Total Billed Charges,7.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,8.24,20,,6.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,26.78,65,,21.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,50,,16.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.82,28.02,
DRUG SCREEN-URINE,4010869,CDM,301,RC,80305,HCPCS,Outpatient,,,20,10.00,,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,19.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,19.58,
C DIF TOX GENS STL QL PCR,4010879,CDM,306,RC,87493,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
TSH WITH REFLEX TO FREE T4,4010897,CDM,301,RC,84443,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,23.84,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,63.04,
URINE CULTURE QUEST,4010899,CDM,306,RC,87086,HCPCS,Outpatient,,,61.8,30.90,,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,42.02,68,,33.616,Percent of Total Billed Charges,68% of Total Billed Charges,11.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,12.36,20,,9.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,40.17,65,,32.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,50,,24.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.46,42.02,
BLOOD CULTURE QUEST,4010901,CDM,306,RC,87040,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,14.65,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.65,63.04,
BACTERIA EYE AEROBE CULT,4010903,CDM,306,RC,87070,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
RAPID COVID-19 RNA,4010931,CDM,306,RC,87635,HCPCS,Outpatient,,,169.95,84.98,,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,115.57,68,,92.456,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,33.99,20,,27.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,110.47,65,,88.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.98,50,,67.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.99,115.57,
OCCULT BLOOD CARD 2,4020024,CDM,301,RC,82272,HCPCS,Outpatient,,,22.66,11.33,,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,15.41,68,,12.328,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,15.41,
GLUCOSE 2-HR POSTPRANDIAL-SERUM,4020053,CDM,301,RC,82947,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,5.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,17.51,
CORTISOL-SERUM (8 A.M. DRAW),4020089,CDM,301,RC,82533,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,23.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.75,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,58.13,
VANCOMYCIN PEAK,4020263,CDM,301,RC,80202,HCPCS,Outpatient,,,133.9,66.95,,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,68,,72.84,Percent of Total Billed Charges,68% of Total Billed Charges,19.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,50,,53.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.23,91.05,
VDRL,4020491,CDM,302,RC,86592,HCPCS,Outpatient,,,36.05,18.03,,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,24.51,68,,19.608,Percent of Total Billed Charges,68% of Total Billed Charges,6.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,7.21,20,,5.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,23.43,65,,18.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,50,,14.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.06,24.51,
GENITAL CULTURE,4020705,CDM,306,RC,87070,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
GC/CHLAMYDIA RNA TMA,4020721,CDM,306,RC,87797,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,17.6,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
EYE GC/CHLAMYDIA RNA TMA,4020725,CDM,306,RC,87797,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,17.6,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
URINALYSIS COMPLETE,4020771,CDM,301,RC,81001,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,4.49,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
C DIF TOX L QL PCR,4020879,CDM,306,RC,87493,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
BLOOD CULTURE LAB CORP,4020901,CDM,306,RC,87040,HCPCS,Outpatient,,,92.7,46.35,,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,63.04,68,,50.432,Percent of Total Billed Charges,68% of Total Billed Charges,14.65,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,18.54,20,,14.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,60.26,65,,48.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.65,63.04,
CULTURE AEROBIC BACTERIA QUEST,4020903,CDM,306,RC,87070,HCPCS,Outpatient,,,69.01,34.51,,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,46.93,68,,37.544,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.51,50,,27.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,46.93,
CULTURE EYE QUEST,4020904,CDM,306,RC,87070,HCPCS,Outpatient,,,69.01,34.51,,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,46.93,68,,37.544,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,44.86,65,,35.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.51,50,,27.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,46.93,
OCCULT BLOOD CARD 3,4030024,CDM,301,RC,82272,HCPCS,Outpatient,,,22.66,11.33,,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,15.41,68,,12.328,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,15.41,
CKMB  REFLEX,4030045,CDM,301,RC,82550,HCPCS,Outpatient,,,22.66,11.33,,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,15.41,68,,12.328,Percent of Total Billed Charges,68% of Total Billed Charges,9.25,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,15.41,
GLUCOSE FASTING-SERUM,4030053,CDM,301,RC,82947,HCPCS,Outpatient,,,25.75,12.88,,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,17.51,68,,14.008,Percent of Total Billed Charges,68% of Total Billed Charges,5.57,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,5.15,20,,4.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,16.74,65,,13.392,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,17.51,
GENTAMYCIN PEAK,4030189,CDM,301,RC,80170,HCPCS,Outpatient,,,75.19,37.60,,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,51.13,68,,40.904,Percent of Total Billed Charges,68% of Total Billed Charges,23.26,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,15.04,20,,12.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,48.87,65,,39.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.6,50,,30.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.04,51.13,
VANCOMYCIN PEAK REF LAB,4030263,CDM,301,RC,80202,HCPCS,Outpatient,,,133.9,66.95,,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,68,,72.84,Percent of Total Billed Charges,68% of Total Billed Charges,19.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,50,,53.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.23,91.05,
SPUTUM CULTURE,4030705,CDM,306,RC,87070,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
T VAGINALIS RRNA XXX QL PCR,4030721,CDM,306,RC,87797,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,17.6,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,52.53,
C DIFF TOXIN B QL REAL TIME PCR,4030879,CDM,306,RC,87493,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
GENITAL AEROBIC CULT,4030903,CDM,306,RC,87070,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
OCCULT BLOOD STOOL - DX X1,4040024,CDM,301,RC,82272,HCPCS,Outpatient,,,22.66,11.33,,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,15.41,68,,12.328,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,4.53,20,,3.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,14.73,65,,11.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,15.41,
VANCOMYCIN TROUGH,4040263,CDM,301,RC,80202,HCPCS,Outpatient,,,133.9,66.95,,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,68,,72.84,Percent of Total Billed Charges,68% of Total Billed Charges,19.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,50,,53.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.23,91.05,
WOUND CULTURE,4040705,CDM,306,RC,87070,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.63,50,,30.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,52.53,
SPUTUM CULTURE QUEST,4040903,CDM,306,RC,87070,HCPCS,Outpatient,,,58.71,29.36,,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,39.92,68,,31.936,Percent of Total Billed Charges,68% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,11.74,20,,9.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,38.16,65,,30.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,50,,23.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,39.92,
VANCOMYCIN TROUGH REF LAB,4050263,CDM,301,RC,80202,HCPCS,Outpatient,,,133.9,66.95,,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,91.05,68,,72.84,Percent of Total Billed Charges,68% of Total Billed Charges,19.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,26.78,20,,21.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,87.04,65,,69.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,50,,53.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.23,91.05,
ABG PUNCTURE,4070103,CDM,301,RC,36600,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,178,
CBC 300,4090004,CDM,300,RC,85025,HCPCS,Outpatient,,,46.35,23.18,,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,31.52,68,,25.216,Percent of Total Billed Charges,68% of Total Billed Charges,11.04,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,9.27,20,,7.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,30.13,65,,24.104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,50,,18.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,31.52,
.UA DIPSTICK WITH MICROSCOPIC,4090008,CDM,301,RC,81001,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,4.49,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
XR ABDOMEN 2V,5000001,CDM,320,RC,74019,HCPCS,Outpatient,,,469,234.50,,304.85,65,,243.88,Percent of Total Billed Charges,65% of Total Billed Charges,318.92,68,,255.136,Percent of Total Billed Charges,68% of Total Billed Charges,20.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,93.8,20,,75.04,Percent of Total Billed Charges,20% of Total Billed Charges,93.8,20,,75.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.8,20,,75.04,Percent of Total Billed Charges,20% of Total Billed Charges,93.8,20,,75.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.85,65,,243.88,Percent of Total Billed Charges,65% of Total Billed Charges,304.85,65,,243.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.68,318.92,
XR ANKLE 3V LEFT,5000002,CDM,320,RC,73610,HCPCS,Outpatient,,,525,262.50,,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,357,68,,285.6,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,357,
XR HAND AP/LATERAL/OBLIQUE VIEW LEFT,5000003,CDM,320,RC,73130,HCPCS,Outpatient,,,530,265.00,,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,360.4,68,,288.32,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,360.4,
XR HIP AP/LATERAL VIEW LEFT,5000004,CDM,320,RC,73502,HCPCS,Outpatient,,,521,260.50,,338.65,65,,270.92,Percent of Total Billed Charges,65% of Total Billed Charges,354.28,68,,283.424,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,104.2,20,,83.36,Percent of Total Billed Charges,20% of Total Billed Charges,104.2,20,,83.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.2,20,,83.36,Percent of Total Billed Charges,20% of Total Billed Charges,104.2,20,,83.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.65,65,,270.92,Percent of Total Billed Charges,65% of Total Billed Charges,338.65,65,,270.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,354.28,
XR KNEE AP/LATERAL VIEW LEFT,5000006,CDM,320,RC,73560,HCPCS,Outpatient,,,370,185.00,,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,251.6,68,,201.28,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,251.6,
XR KUB,5000007,CDM,320,RC,74018,HCPCS,Outpatient,,,386,193.00,,250.9,65,,200.72,Percent of Total Billed Charges,65% of Total Billed Charges,262.48,68,,209.984,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,77.2,20,,61.76,Percent of Total Billed Charges,20% of Total Billed Charges,77.2,20,,61.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.2,20,,61.76,Percent of Total Billed Charges,20% of Total Billed Charges,77.2,20,,61.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.9,65,,200.72,Percent of Total Billed Charges,65% of Total Billed Charges,250.9,65,,200.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,262.48,
XR SHOULDER AP VIEW ROUTINE LEFT,5000008,CDM,320,RC,73020,HCPCS,Outpatient,,,185,92.50,,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,180,
XR SKULL ENTIRE,5000009,CDM,320,RC,70260,HCPCS,Outpatient,,,316.21,158.11,,205.54,65,,164.432,Percent of Total Billed Charges,65% of Total Billed Charges,215.02,68,,172.016,Percent of Total Billed Charges,68% of Total Billed Charges,30.04,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,63.24,20,,50.592,Percent of Total Billed Charges,20% of Total Billed Charges,63.24,20,,50.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.24,20,,50.592,Percent of Total Billed Charges,20% of Total Billed Charges,63.24,20,,50.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.54,65,,164.432,Percent of Total Billed Charges,65% of Total Billed Charges,205.54,65,,164.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.04,215.02,
XR AC JOINTS,5000010,CDM,320,RC,73050,HCPCS,Outpatient,,,335,167.50,,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,227.8,68,,182.24,Percent of Total Billed Charges,68% of Total Billed Charges,22.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.37,227.8,
XR BONE AGE,5000011,CDM,320,RC,77072,HCPCS,Outpatient,,,248,124.00,,161.2,65,,128.96,Percent of Total Billed Charges,65% of Total Billed Charges,168.64,68,,134.912,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,49.6,20,,39.68,Percent of Total Billed Charges,20% of Total Billed Charges,49.6,20,,39.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.6,20,,39.68,Percent of Total Billed Charges,20% of Total Billed Charges,49.6,20,,39.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.2,65,,128.96,Percent of Total Billed Charges,65% of Total Billed Charges,161.2,65,,128.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,180,
XR RIBS 4 VIEWS (UNSPECIFIED) VIEW LEFT,5000012,CDM,320,RC,71101,HCPCS,Outpatient,,,700,350.00,,455,65,,364,Percent of Total Billed Charges,65% of Total Billed Charges,476,68,,380.8,Percent of Total Billed Charges,68% of Total Billed Charges,22.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,140,20,,112,Percent of Total Billed Charges,20% of Total Billed Charges,140,20,,112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140,20,,112,Percent of Total Billed Charges,20% of Total Billed Charges,140,20,,112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455,65,,364,Percent of Total Billed Charges,65% of Total Billed Charges,455,65,,364,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.37,476,
XR RIBS 3 VIEWS (UNSPECIFIED) VIEW BILAT,5000013,CDM,320,RC,71111,HCPCS,Outpatient,,,300,150.00,,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,30.04,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.04,204,
XR KNEE AP/LAT/OBLIQUE VIEW LEFT,5000014,CDM,320,RC,73564,HCPCS,Outpatient,,,570,285.00,,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,387.6,68,,310.08,Percent of Total Billed Charges,68% of Total Billed Charges,20.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,387.6,
XR CLAVICLE 2 VIEWS LEFT,5000015,CDM,320,RC,73000,HCPCS,Outpatient,,,525,262.50,,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,357,68,,285.6,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,357,
XR COCCYX/SACRUM MIN 2V,5000016,CDM,320,RC,72220,HCPCS,Outpatient,,,438,219.00,,284.7,65,,227.76,Percent of Total Billed Charges,65% of Total Billed Charges,297.84,68,,238.272,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,87.6,20,,70.08,Percent of Total Billed Charges,20% of Total Billed Charges,87.6,20,,70.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.6,20,,70.08,Percent of Total Billed Charges,20% of Total Billed Charges,87.6,20,,70.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.7,65,,227.76,Percent of Total Billed Charges,65% of Total Billed Charges,284.7,65,,227.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,297.84,
XR ELBOW AP/LATERAL/OBLIQUE VIEW LEFT,5000017,CDM,320,RC,73080,HCPCS,Outpatient,,,505,252.50,,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,343.4,68,,274.72,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,343.4,
XR EYE FOREIGN BODY,5000018,CDM,320,RC,70030,HCPCS,Outpatient,,,352,176.00,,228.8,65,,183.04,Percent of Total Billed Charges,65% of Total Billed Charges,239.36,68,,191.488,Percent of Total Billed Charges,68% of Total Billed Charges,14.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,70.4,20,,56.32,Percent of Total Billed Charges,20% of Total Billed Charges,70.4,20,,56.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.4,20,,56.32,Percent of Total Billed Charges,20% of Total Billed Charges,70.4,20,,56.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.8,65,,183.04,Percent of Total Billed Charges,65% of Total Billed Charges,228.8,65,,183.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.22,239.36,
XR FACIAL BONES COMPLETE,5000019,CDM,320,RC,70150,HCPCS,Outpatient,,,675,337.50,,438.75,65,,351,Percent of Total Billed Charges,65% of Total Billed Charges,459,68,,367.2,Percent of Total Billed Charges,68% of Total Billed Charges,26.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,135,20,,108,Percent of Total Billed Charges,20% of Total Billed Charges,135,20,,108,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135,20,,108,Percent of Total Billed Charges,20% of Total Billed Charges,135,20,,108,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.75,65,,351,Percent of Total Billed Charges,65% of Total Billed Charges,438.75,65,,351,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.36,459,
XR FEMUR AP/LATERAL VIEW LEFT,5000020,CDM,320,RC,73552,HCPCS,Outpatient,,,455,227.50,,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,309.4,68,,247.52,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,309.4,
XR WRIST 3V LEFT,5000021,CDM,320,RC,73110,HCPCS,Outpatient,,,480,240.00,,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,326.4,68,,261.12,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,326.4,
XR WRIST 2V LEFT,5000022,CDM,320,RC,73100,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
XR ZYGOMATIC ARCH 3V,5000023,CDM,320,RC,70150,HCPCS,Outpatient,,,675,337.50,,438.75,65,,351,Percent of Total Billed Charges,65% of Total Billed Charges,459,68,,367.2,Percent of Total Billed Charges,68% of Total Billed Charges,26.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,135,20,,108,Percent of Total Billed Charges,20% of Total Billed Charges,135,20,,108,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135,20,,108,Percent of Total Billed Charges,20% of Total Billed Charges,135,20,,108,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.75,65,,351,Percent of Total Billed Charges,65% of Total Billed Charges,438.75,65,,351,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.36,459,
XR TIB/FIB MIN 2 V LEFT,5000024,CDM,320,RC,73590,HCPCS,Outpatient,,,489,244.50,,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,332.52,68,,266.016,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,332.52,
XR FINGER 2V LEFT,5000025,CDM,320,RC,73140,HCPCS,Outpatient,,,427,213.50,,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,290.36,68,,232.288,Percent of Total Billed Charges,68% of Total Billed Charges,14.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.22,290.36,
XR FOOT AP/LATERAL/OBLIQUE VIEW LEFT,5000026,CDM,320,RC,73630,HCPCS,Outpatient,,,505,252.50,,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,343.4,68,,274.72,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,343.4,
XR FOREARM AP/LATERAL VIEW LEFT,5000027,CDM,320,RC,73090,HCPCS,Outpatient,,,464,232.00,,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,315.52,68,,252.416,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,315.52,
XR CALCANEUS AP/LATERAL VIEW LEFT,5000028,CDM,320,RC,73650,HCPCS,Outpatient,,,422,211.00,,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,286.96,68,,229.568,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,286.96,
XR HIP AP/LATERAL VIEW BILAT,5000029,CDM,320,RC,73521,HCPCS,Outpatient,,,608,304.00,,395.2,65,,316.16,Percent of Total Billed Charges,65% of Total Billed Charges,413.44,68,,330.752,Percent of Total Billed Charges,68% of Total Billed Charges,22.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,121.6,20,,97.28,Percent of Total Billed Charges,20% of Total Billed Charges,121.6,20,,97.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.6,20,,97.28,Percent of Total Billed Charges,20% of Total Billed Charges,121.6,20,,97.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395.2,65,,316.16,Percent of Total Billed Charges,65% of Total Billed Charges,395.2,65,,316.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.37,413.44,
XR HUMERUS 2V LEFT,5000030,CDM,320,RC,73060,HCPCS,Outpatient,,,433,216.50,,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,294.44,68,,235.552,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,294.44,
XR MANDIBLE 4V,5000031,CDM,320,RC,70110,HCPCS,Outpatient,,,474,237.00,,308.1,65,,246.48,Percent of Total Billed Charges,65% of Total Billed Charges,322.32,68,,257.856,Percent of Total Billed Charges,68% of Total Billed Charges,20.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.1,65,,246.48,Percent of Total Billed Charges,65% of Total Billed Charges,308.1,65,,246.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,322.32,
XR NASAL BONES-COMPLETE,5000034,CDM,320,RC,70160,HCPCS,Outpatient,,,433,216.50,,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,294.44,68,,235.552,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,294.44,
XR ORBITS,5000035,CDM,320,RC,70200,HCPCS,Outpatient,,,526,263.00,,341.9,65,,273.52,Percent of Total Billed Charges,65% of Total Billed Charges,357.68,68,,286.144,Percent of Total Billed Charges,68% of Total Billed Charges,26.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,105.2,20,,84.16,Percent of Total Billed Charges,20% of Total Billed Charges,105.2,20,,84.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.2,20,,84.16,Percent of Total Billed Charges,20% of Total Billed Charges,105.2,20,,84.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.9,65,,273.52,Percent of Total Billed Charges,65% of Total Billed Charges,341.9,65,,273.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.36,357.68,
XR PELVIS ROUTINE,5000036,CDM,320,RC,72170,HCPCS,Outpatient,,,567,283.50,,368.55,65,,294.84,Percent of Total Billed Charges,65% of Total Billed Charges,385.56,68,,308.448,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,113.4,20,,90.72,Percent of Total Billed Charges,20% of Total Billed Charges,113.4,20,,90.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,20,,90.72,Percent of Total Billed Charges,20% of Total Billed Charges,113.4,20,,90.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.55,65,,294.84,Percent of Total Billed Charges,65% of Total Billed Charges,368.55,65,,294.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,385.56,
XR S I JOINTS LEFT,5000037,CDM,320,RC,72200,HCPCS,Outpatient,,,158.62,79.31,,103.1,65,,82.48,Percent of Total Billed Charges,65% of Total Billed Charges,107.86,68,,86.288,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.1,65,,82.48,Percent of Total Billed Charges,65% of Total Billed Charges,103.1,65,,82.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,180,
XR SCAPULA 2 VIEWS (UNSPECIFIED) LEFT,5000038,CDM,320,RC,73010,HCPCS,Outpatient,,,577,288.50,,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,392.36,68,,313.888,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,392.36,
XR SHOULDER AP/LATERAL/AXILLARY LEFT,5000040,CDM,320,RC,73030,HCPCS,Outpatient,,,515,257.50,,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,350.2,68,,280.16,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,350.2,
XR SINUS 3 VIEWS,5000041,CDM,320,RC,70220,HCPCS,Outpatient,,,592,296.00,,384.8,65,,307.84,Percent of Total Billed Charges,65% of Total Billed Charges,402.56,68,,322.048,Percent of Total Billed Charges,68% of Total Billed Charges,26.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,118.4,20,,94.72,Percent of Total Billed Charges,20% of Total Billed Charges,118.4,20,,94.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.4,20,,94.72,Percent of Total Billed Charges,20% of Total Billed Charges,118.4,20,,94.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.8,65,,307.84,Percent of Total Billed Charges,65% of Total Billed Charges,384.8,65,,307.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.36,402.56,
XR SKULL ENTIRE PA/LATERAL VIEW ROUTINE,5000042,CDM,320,RC,70250,HCPCS,Outpatient,,,434,217.00,,282.1,65,,225.68,Percent of Total Billed Charges,65% of Total Billed Charges,295.12,68,,236.096,Percent of Total Billed Charges,68% of Total Billed Charges,20.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,86.8,20,,69.44,Percent of Total Billed Charges,20% of Total Billed Charges,86.8,20,,69.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.8,20,,69.44,Percent of Total Billed Charges,20% of Total Billed Charges,86.8,20,,69.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.1,65,,225.68,Percent of Total Billed Charges,65% of Total Billed Charges,282.1,65,,225.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,295.12,
XR CERVICAL SPINE COMPLETE VIEW,5000043,CDM,320,RC,72052,HCPCS,Outpatient,,,773,386.50,,502.45,65,,401.96,Percent of Total Billed Charges,65% of Total Billed Charges,525.64,68,,420.512,Percent of Total Billed Charges,68% of Total Billed Charges,37.86,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,154.6,20,,123.68,Percent of Total Billed Charges,20% of Total Billed Charges,154.6,20,,123.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.6,20,,123.68,Percent of Total Billed Charges,20% of Total Billed Charges,154.6,20,,123.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.45,65,,401.96,Percent of Total Billed Charges,65% of Total Billed Charges,502.45,65,,401.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.86,525.64,
XR CERVICAL SPINE AP/LATERAL VIEW,5000044,CDM,320,RC,72040,HCPCS,Outpatient,,,474,237.00,,308.1,65,,246.48,Percent of Total Billed Charges,65% of Total Billed Charges,322.32,68,,257.856,Percent of Total Billed Charges,68% of Total Billed Charges,20.13,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,94.8,20,,75.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.1,65,,246.48,Percent of Total Billed Charges,65% of Total Billed Charges,308.1,65,,246.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.13,322.32,
XR THORACIC SPINE AP/LAT/SWIMMERS VIEW,5000045,CDM,320,RC,72072,HCPCS,Outpatient,,,469,234.50,,304.85,65,,243.88,Percent of Total Billed Charges,65% of Total Billed Charges,318.92,68,,255.136,Percent of Total Billed Charges,68% of Total Billed Charges,24.76,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,93.8,20,,75.04,Percent of Total Billed Charges,20% of Total Billed Charges,93.8,20,,75.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.8,20,,75.04,Percent of Total Billed Charges,20% of Total Billed Charges,93.8,20,,75.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.85,65,,243.88,Percent of Total Billed Charges,65% of Total Billed Charges,304.85,65,,243.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.76,318.92,
XR LUMBAR SPINE AP/LATERAL/OBLIQUE VIEW,5000046,CDM,320,RC,72110,HCPCS,Outpatient,,,300,150.00,,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,30.67,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.67,204,
XR LUMBAR SPINE AP/LATERAL VIEW,5000047,CDM,320,RC,72100,HCPCS,Outpatient,,,504,252.00,,327.6,65,,262.08,Percent of Total Billed Charges,65% of Total Billed Charges,342.72,68,,274.176,Percent of Total Billed Charges,68% of Total Billed Charges,22.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,100.8,20,,80.64,Percent of Total Billed Charges,20% of Total Billed Charges,100.8,20,,80.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.8,20,,80.64,Percent of Total Billed Charges,20% of Total Billed Charges,100.8,20,,80.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327.6,65,,262.08,Percent of Total Billed Charges,65% of Total Billed Charges,327.6,65,,262.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.37,342.72,
XR STERNUM 2 VIEWS,5000048,CDM,320,RC,71120,HCPCS,Outpatient,,,300,150.00,,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,21.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.73,204,
XR TMJ BILATERAL,5000049,CDM,320,RC,70330,HCPCS,Outpatient,,,625,312.50,,406.25,65,,325,Percent of Total Billed Charges,65% of Total Billed Charges,425,68,,340,Percent of Total Billed Charges,68% of Total Billed Charges,27.96,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,125,20,,100,Percent of Total Billed Charges,20% of Total Billed Charges,125,20,,100,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125,20,,100,Percent of Total Billed Charges,20% of Total Billed Charges,125,20,,100,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.25,65,,325,Percent of Total Billed Charges,65% of Total Billed Charges,406.25,65,,325,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.96,425,
XR TOE 2V LEFT,5000050,CDM,320,RC,73660,HCPCS,Outpatient,,,319,159.50,,207.35,65,,165.88,Percent of Total Billed Charges,65% of Total Billed Charges,216.92,68,,173.536,Percent of Total Billed Charges,68% of Total Billed Charges,14.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,63.8,20,,51.04,Percent of Total Billed Charges,20% of Total Billed Charges,63.8,20,,51.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.8,20,,51.04,Percent of Total Billed Charges,20% of Total Billed Charges,63.8,20,,51.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.35,65,,165.88,Percent of Total Billed Charges,65% of Total Billed Charges,207.35,65,,165.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.22,216.92,
CHEST PORTABLE AP,5000051,CDM,320,RC,71045,HCPCS,Outpatient,,,335,167.50,,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,227.8,68,,182.24,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,227.8,
XR FLOURO <1HR,5000052,CDM,320,RC,76000,HCPCS,Outpatient,,,1049,524.50,,681.85,65,,545.48,Percent of Total Billed Charges,65% of Total Billed Charges,713.32,68,,570.656,Percent of Total Billed Charges,68% of Total Billed Charges,43.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,209.8,20,,167.84,Percent of Total Billed Charges,20% of Total Billed Charges,209.8,20,,167.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.8,20,,167.84,Percent of Total Billed Charges,20% of Total Billed Charges,209.8,20,,167.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,681.85,65,,545.48,Percent of Total Billed Charges,65% of Total Billed Charges,681.85,65,,545.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.45,713.32,
XR BARIUM ENEMA,5000054,CDM,320,RC,74270,HCPCS,Outpatient,,,876,438.00,,569.4,65,,455.52,Percent of Total Billed Charges,65% of Total Billed Charges,595.68,68,,476.544,Percent of Total Billed Charges,68% of Total Billed Charges,57.03,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,175.2,20,,140.16,Percent of Total Billed Charges,20% of Total Billed Charges,175.2,20,,140.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.2,20,,140.16,Percent of Total Billed Charges,20% of Total Billed Charges,175.2,20,,140.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,569.4,65,,455.52,Percent of Total Billed Charges,65% of Total Billed Charges,569.4,65,,455.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,595.68,
UPPER GI SERIES,5000056,CDM,320,RC,74246,HCPCS,Outpatient,,,1048,524.00,,681.2,65,,544.96,Percent of Total Billed Charges,65% of Total Billed Charges,712.64,68,,570.112,Percent of Total Billed Charges,68% of Total Billed Charges,54.96,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,209.6,20,,167.68,Percent of Total Billed Charges,20% of Total Billed Charges,209.6,20,,167.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.6,20,,167.68,Percent of Total Billed Charges,20% of Total Billed Charges,209.6,20,,167.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,681.2,65,,544.96,Percent of Total Billed Charges,65% of Total Billed Charges,681.2,65,,544.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,712.64,
VOID CYSTOURETHOGRAM,5000057,CDM,320,RC,74455,HCPCS,Outpatient,,,327.83,163.92,,213.09,65,,170.472,Percent of Total Billed Charges,65% of Total Billed Charges,222.92,68,,178.336,Percent of Total Billed Charges,68% of Total Billed Charges,52.72,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,65.57,20,,52.456,Percent of Total Billed Charges,20% of Total Billed Charges,65.57,20,,52.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.57,20,,52.456,Percent of Total Billed Charges,20% of Total Billed Charges,65.57,20,,52.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.09,65,,170.472,Percent of Total Billed Charges,65% of Total Billed Charges,213.09,65,,170.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.72,222.92,
XR BE W/AIR CONTRAST,5000058,CDM,320,RC,74280,HCPCS,Outpatient,,,1159,579.50,,753.35,65,,602.68,Percent of Total Billed Charges,65% of Total Billed Charges,788.12,68,,630.496,Percent of Total Billed Charges,68% of Total Billed Charges,74.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,231.8,20,,185.44,Percent of Total Billed Charges,20% of Total Billed Charges,231.8,20,,185.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.8,20,,185.44,Percent of Total Billed Charges,20% of Total Billed Charges,231.8,20,,185.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,753.35,65,,602.68,Percent of Total Billed Charges,65% of Total Billed Charges,753.35,65,,602.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,788.12,
XR BARIUM SWALLOW/ESOPHAGRAM,5000059,CDM,320,RC,74210,HCPCS,Outpatient,,,257.19,128.60,,167.17,65,,133.736,Percent of Total Billed Charges,65% of Total Billed Charges,174.89,68,,139.912,Percent of Total Billed Charges,68% of Total Billed Charges,39.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,51.44,20,,41.152,Percent of Total Billed Charges,20% of Total Billed Charges,51.44,20,,41.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.44,20,,41.152,Percent of Total Billed Charges,20% of Total Billed Charges,51.44,20,,41.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.17,65,,133.736,Percent of Total Billed Charges,65% of Total Billed Charges,167.17,65,,133.736,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.46,180,
XR GI W SMALL BOWEL,5000060,CDM,320,RC,,,Outpatient,,,509.85,254.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.97,20,,81.576,Percent of Total Billed Charges,20% of Total Billed Charges,101.97,20,,81.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.97,20,,81.576,Percent of Total Billed Charges,20% of Total Billed Charges,101.97,20,,81.576,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,331.4,65,,265.12,Percent of Total Billed Charges,65% of Total Billed Charges,331.4,65,,265.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,331.4,
XR NECK SOFT TISSUE BILATERAL,5000062,CDM,320,RC,70360,HCPCS,Outpatient,,,443,221.50,,287.95,65,,230.36,Percent of Total Billed Charges,65% of Total Billed Charges,301.24,68,,240.992,Percent of Total Billed Charges,68% of Total Billed Charges,14.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,88.6,20,,70.88,Percent of Total Billed Charges,20% of Total Billed Charges,88.6,20,,70.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.6,20,,70.88,Percent of Total Billed Charges,20% of Total Billed Charges,88.6,20,,70.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.95,65,,230.36,Percent of Total Billed Charges,65% of Total Billed Charges,287.95,65,,230.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.22,301.24,
XR ELBOW AP/LATERAL VIEW LEFT,5000063,CDM,320,RC,73070,HCPCS,Outpatient,,,358,179.00,,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,243.44,68,,194.752,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,243.44,
XR ANKLE 3V RIGHT,5000064,CDM,320,RC,73610,HCPCS,Outpatient,,,525,262.50,,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,357,68,,285.6,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,357,
XR ANKLE 3V BILATERAL,5000065,CDM,320,RC,73610,HCPCS,Outpatient,,,525,262.50,,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,357,68,,285.6,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,357,
XR RIBS 4 VIEWS (UNSPECIFIED) VIEW RIGHT,5000066,CDM,320,RC,71101,HCPCS,Outpatient,,,700,350.00,,455,65,,364,Percent of Total Billed Charges,65% of Total Billed Charges,476,68,,380.8,Percent of Total Billed Charges,68% of Total Billed Charges,22.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,140,20,,112,Percent of Total Billed Charges,20% of Total Billed Charges,140,20,,112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140,20,,112,Percent of Total Billed Charges,20% of Total Billed Charges,140,20,,112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455,65,,364,Percent of Total Billed Charges,65% of Total Billed Charges,455,65,,364,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.37,476,
XR CLAVICLE 2 VIEWS RIGHT,5000067,CDM,320,RC,73000,HCPCS,Outpatient,,,525,262.50,,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,357,68,,285.6,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,357,
XR CLAVICLE 2 VIEWS BILATERAL,5000068,CDM,320,RC,73000,HCPCS,Outpatient,,,525,262.50,,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,357,68,,285.6,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,357,
XR ELBOW AP/LATERAL/OBLIQUE VIEW RIGHT,5000069,CDM,320,RC,73080,HCPCS,Outpatient,,,525,262.50,,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,357,68,,285.6,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,105,20,,84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,341.25,65,,273,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,357,
XR ELBOW AP/LATERAL/OBLIQUE VIEW BILAT,5000070,CDM,320,RC,73080,HCPCS,Outpatient,,,505,252.50,,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,343.4,68,,274.72,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,343.4,
XR ELBOW AP/LATERAL VIEW RIGHT,5000071,CDM,320,RC,73070,HCPCS,Outpatient,,,358,179.00,,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,243.44,68,,194.752,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,243.44,
XR FEMUR AP/LATERAL VIEW RIGHT,5000072,CDM,320,RC,73552,HCPCS,Outpatient,,,455,227.50,,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,309.4,68,,247.52,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,309.4,
XR FEMUR AP/LATERAL VIEW BILATERAL,5000073,CDM,320,RC,73552,HCPCS,Outpatient,,,455,227.50,,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,309.4,68,,247.52,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,91,20,,72.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,295.75,65,,236.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,309.4,
XR FINGER 2V RIGHT,5000074,CDM,320,RC,73140,HCPCS,Outpatient,,,427,213.50,,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,290.36,68,,232.288,Percent of Total Billed Charges,68% of Total Billed Charges,14.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.22,290.36,
XR FINGER 2V BILATERAL,5000075,CDM,320,RC,73140,HCPCS,Outpatient,,,427,213.50,,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,290.36,68,,232.288,Percent of Total Billed Charges,68% of Total Billed Charges,14.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,85.4,20,,68.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,277.55,65,,222.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.22,290.36,
XR FOOT AP/LATERAL/OBLIQUE VIEW RIGHT,5000076,CDM,320,RC,73630,HCPCS,Outpatient,,,505,252.50,,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,343.4,68,,274.72,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,343.4,
XR FOOT AP/LATERAL/OBLIQUE VIEW BILAT,5000077,CDM,320,RC,73630,HCPCS,Outpatient,,,505,252.50,,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,343.4,68,,274.72,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,101,20,,80.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,328.25,65,,262.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,343.4,
XR FOREARM AP/LATERAL VIEW RIGHT,5000078,CDM,320,RC,73090,HCPCS,Outpatient,,,464,232.00,,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,315.52,68,,252.416,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,315.52,
XR FOREARM AP/LATERAL VIEW BILAT,5000079,CDM,320,RC,73090,HCPCS,Outpatient,,,464,232.00,,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,315.52,68,,252.416,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,92.8,20,,74.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,301.6,65,,241.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,315.52,
XR HAND AP/LATERAL/OBLIQUE VIEW RIGHT,5000080,CDM,320,RC,73130,HCPCS,Outpatient,,,530,265.00,,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,360.4,68,,288.32,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,360.4,
XR HAND AP/LATERAL/OBLIQUE VIEW BILAT,5000081,CDM,320,RC,73130,HCPCS,Outpatient,,,530,265.00,,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,360.4,68,,288.32,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,106,20,,84.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,344.5,65,,275.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,360.4,
XR CALCANEUS AP/LATERAL VIEW RIGHT,5000082,CDM,320,RC,73650,HCPCS,Outpatient,,,422,211.00,,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,286.96,68,,229.568,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,286.96,
XR CALCANEUS BILATERAL,5000083,CDM,320,RC,73650,HCPCS,Outpatient,,,422,211.00,,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,286.96,68,,229.568,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,84.4,20,,67.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,274.3,65,,219.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,286.96,
XR HIP AP/LATERAL VIEW RIGHT,5000084,CDM,320,RC,73502,HCPCS,Outpatient,,,501,250.50,,325.65,65,,260.52,Percent of Total Billed Charges,65% of Total Billed Charges,340.68,68,,272.544,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,100.2,20,,80.16,Percent of Total Billed Charges,20% of Total Billed Charges,100.2,20,,80.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.2,20,,80.16,Percent of Total Billed Charges,20% of Total Billed Charges,100.2,20,,80.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.65,65,,260.52,Percent of Total Billed Charges,65% of Total Billed Charges,325.65,65,,260.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,340.68,
XR HUMERUS 2V RIGHT,5000085,CDM,320,RC,73060,HCPCS,Outpatient,,,433,216.50,,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,294.44,68,,235.552,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,294.44,
XR HUMERUS 2V BILAT,5000086,CDM,320,RC,73060,HCPCS,Outpatient,,,433,216.50,,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,294.44,68,,235.552,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,86.6,20,,69.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,281.45,65,,225.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,294.44,
XR KNEE AP/LATERAL VIEW RIGHT,5000087,CDM,320,RC,73560,HCPCS,Outpatient,,,370,185.00,,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,251.6,68,,201.28,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,251.6,
XR KNEE AP/LATERAL VIEW BILAT,5000088,CDM,320,RC,73560,HCPCS,Outpatient,,,370,185.00,,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,251.6,68,,201.28,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,74,20,,59.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,240.5,65,,192.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,251.6,
XR KNEE AP/LAT/OBLIQUE VIEW RIGHT,5000089,CDM,320,RC,73564,HCPCS,Outpatient,,,570,285.00,,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,387.6,68,,310.08,Percent of Total Billed Charges,68% of Total Billed Charges,20.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,387.6,
XR KNEE AP/LAT/OBLIQUE VIEW BILAT,5000090,CDM,320,RC,73564,HCPCS,Outpatient,,,570,285.00,,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,387.6,68,,310.08,Percent of Total Billed Charges,68% of Total Billed Charges,20.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,114,20,,91.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,370.5,65,,296.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,387.6,
XR S I JOINTS RIGHT,5000091,CDM,320,RC,72200,HCPCS,Outpatient,,,158.62,79.31,,103.1,65,,82.48,Percent of Total Billed Charges,65% of Total Billed Charges,107.86,68,,86.288,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,31.72,20,,25.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.1,65,,82.48,Percent of Total Billed Charges,65% of Total Billed Charges,103.1,65,,82.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,180,
XR S I JOINTS BILAT,5000092,CDM,320,RC,72200,HCPCS,Outpatient,,,273.98,136.99,,178.09,65,,142.472,Percent of Total Billed Charges,65% of Total Billed Charges,186.31,68,,149.048,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,54.8,20,,43.84,Percent of Total Billed Charges,20% of Total Billed Charges,54.8,20,,43.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.8,20,,43.84,Percent of Total Billed Charges,20% of Total Billed Charges,54.8,20,,43.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.09,65,,142.472,Percent of Total Billed Charges,65% of Total Billed Charges,178.09,65,,142.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,186.31,
XR SCAPULA 2 VIEWS (UNSPECIFIED) RIGHT,5000093,CDM,320,RC,73010,HCPCS,Outpatient,,,577,288.50,,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,392.36,68,,313.888,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,392.36,
XR SCAPULA BILATERAL,5000094,CDM,320,RC,73010,HCPCS,Outpatient,,,577,288.50,,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,392.36,68,,313.888,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,115.4,20,,92.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,375.05,65,,300.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,392.36,
XR SHOULDER AP VIEW ROUTINE RIGHT,5000095,CDM,320,RC,73020,HCPCS,Outpatient,,,185,92.50,,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,180,
XR SHOULDER AP VIEW ROUTINE BILAT,5000096,CDM,320,RC,73020,HCPCS,Outpatient,,,185,92.50,,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,180,
XR SHOULDER AP/LATERAL/AXILLARY RIGHT,5000097,CDM,320,RC,73030,HCPCS,Outpatient,,,185,92.50,,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,180,
XR SHOULDER AP/LATERAL/AXILLARY BILAT,5000098,CDM,320,RC,73030,HCPCS,Outpatient,,,515,257.50,,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,350.2,68,,280.16,Percent of Total Billed Charges,68% of Total Billed Charges,19.17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.17,350.2,
XR TIB/FIB MIN 2V RIGHT,5000099,CDM,320,RC,73590,HCPCS,Outpatient,,,489,244.50,,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,332.52,68,,266.016,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,332.52,
XR TIB/FIB MIN 2V BILAT,5000100,CDM,320,RC,73590,HCPCS,Outpatient,,,489,244.50,,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,332.52,68,,266.016,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,97.8,20,,78.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,317.85,65,,254.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,332.52,
XR TOE 2V RIGHT,5000101,CDM,320,RC,73660,HCPCS,Outpatient,,,319,159.50,,207.35,65,,165.88,Percent of Total Billed Charges,65% of Total Billed Charges,216.92,68,,173.536,Percent of Total Billed Charges,68% of Total Billed Charges,14.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,63.8,20,,51.04,Percent of Total Billed Charges,20% of Total Billed Charges,63.8,20,,51.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.8,20,,51.04,Percent of Total Billed Charges,20% of Total Billed Charges,63.8,20,,51.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.35,65,,165.88,Percent of Total Billed Charges,65% of Total Billed Charges,207.35,65,,165.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.22,216.92,
XR WRIST 2V RIGHT,5000102,CDM,320,RC,73100,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
XR WRIST 2V BILAT,5000103,CDM,320,RC,73100,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
XR WRIST 3V RIGHT,5000104,CDM,320,RC,73110,HCPCS,Outpatient,,,480,240.00,,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,326.4,68,,261.12,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,326.4,
XR WRIST 3V BILAT,5000105,CDM,320,RC,73110,HCPCS,Outpatient,,,480,240.00,,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,326.4,68,,261.12,Percent of Total Billed Charges,68% of Total Billed Charges,17.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.73,326.4,
SCR/BAR ENE-ALT SIGM,5000106,CDM,320,RC,G0106,HCPCS,Outpatient,,,371.83,185.92,,241.69,65,,193.352,Percent of Total Billed Charges,65% of Total Billed Charges,252.84,68,,202.272,Percent of Total Billed Charges,68% of Total Billed Charges,132.62,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,74.37,20,,59.496,Percent of Total Billed Charges,20% of Total Billed Charges,74.37,20,,59.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.37,20,,59.496,Percent of Total Billed Charges,20% of Total Billed Charges,74.37,20,,59.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.69,65,,193.352,Percent of Total Billed Charges,65% of Total Billed Charges,241.69,65,,193.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,252.84,
SCR/BAR ENE ALT-COLO,5000107,CDM,320,RC,G0106,HCPCS,Outpatient,,,371.83,185.92,,241.69,65,,193.352,Percent of Total Billed Charges,65% of Total Billed Charges,252.84,68,,202.272,Percent of Total Billed Charges,68% of Total Billed Charges,132.62,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,74.37,20,,59.496,Percent of Total Billed Charges,20% of Total Billed Charges,74.37,20,,59.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.37,20,,59.496,Percent of Total Billed Charges,20% of Total Billed Charges,74.37,20,,59.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.69,65,,193.352,Percent of Total Billed Charges,65% of Total Billed Charges,241.69,65,,193.352,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,252.84,
FISTULAGRAM,5000108,CDM,320,RC,20501,HCPCS,Outpatient,,,433.63,216.82,,281.86,65,,225.488,Percent of Total Billed Charges,65% of Total Billed Charges,294.87,68,,235.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.73,20,,69.384,Percent of Total Billed Charges,20% of Total Billed Charges,86.73,20,,69.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.73,20,,69.384,Percent of Total Billed Charges,20% of Total Billed Charges,86.73,20,,69.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.86,65,,225.488,Percent of Total Billed Charges,65% of Total Billed Charges,281.86,65,,225.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,294.87,
XR SINUS WATERS VIEW,5000109,CDM,320,RC,70210,HCPCS,Outpatient,,,480,240.00,,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,326.4,68,,261.12,Percent of Total Billed Charges,68% of Total Billed Charges,20.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,96,20,,76.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,312,65,,249.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,326.4,
XR KIDDOGRAM,5000110,CDM,320,RC,77076,HCPCS,Outpatient,,,1007,503.50,,654.55,65,,523.64,Percent of Total Billed Charges,65% of Total Billed Charges,684.76,68,,547.808,Percent of Total Billed Charges,68% of Total Billed Charges,24.76,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,201.4,20,,161.12,Percent of Total Billed Charges,20% of Total Billed Charges,201.4,20,,161.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.4,20,,161.12,Percent of Total Billed Charges,20% of Total Billed Charges,201.4,20,,161.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,654.55,65,,523.64,Percent of Total Billed Charges,65% of Total Billed Charges,654.55,65,,523.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.76,684.76,
XR T TUBE CHOLANGIOGRAM,5000111,CDM,320,RC,74320,HCPCS,Outpatient,,,487.19,243.60,,316.67,65,,253.336,Percent of Total Billed Charges,65% of Total Billed Charges,331.29,68,,265.032,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.44,20,,77.952,Percent of Total Billed Charges,20% of Total Billed Charges,97.44,20,,77.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.44,20,,77.952,Percent of Total Billed Charges,20% of Total Billed Charges,97.44,20,,77.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.67,65,,253.336,Percent of Total Billed Charges,65% of Total Billed Charges,316.67,65,,253.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,331.29,
XR ABDOMEN SERIES,5000112,CDM,320,RC,74022,HCPCS,Outpatient,,,773,386.50,,502.45,65,,401.96,Percent of Total Billed Charges,65% of Total Billed Charges,525.64,68,,420.512,Percent of Total Billed Charges,68% of Total Billed Charges,24.76,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,154.6,20,,123.68,Percent of Total Billed Charges,20% of Total Billed Charges,154.6,20,,123.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.6,20,,123.68,Percent of Total Billed Charges,20% of Total Billed Charges,154.6,20,,123.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.45,65,,401.96,Percent of Total Billed Charges,65% of Total Billed Charges,502.45,65,,401.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.76,525.64,
XR ANKLE 2V BILATERAL,5000113,CDM,320,RC,73600,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
XR ANKLE 2V RIGHT,5000114,CDM,320,RC,73600,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
XR ANKLE 2V LEFT,5000115,CDM,320,RC,73600,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
CYSTOGRAM MIN 3VW,5000116,CDM,320,RC,51600,HCPCS,Outpatient,,,489.25,244.63,,318.01,65,,254.408,Percent of Total Billed Charges,65% of Total Billed Charges,332.69,68,,266.152,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,97.85,20,,78.28,Percent of Total Billed Charges,20% of Total Billed Charges,97.85,20,,78.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.85,20,,78.28,Percent of Total Billed Charges,20% of Total Billed Charges,97.85,20,,78.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,318.01,65,,254.408,Percent of Total Billed Charges,65% of Total Billed Charges,318.01,65,,254.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,332.69,
XR ELBOW AP/LATERAL VIEW BILATERAL,5000117,CDM,320,RC,73070,HCPCS,Outpatient,,,358,179.00,,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,243.44,68,,194.752,Percent of Total Billed Charges,68% of Total Billed Charges,17.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.41,243.44,
XR FOOT AP/LATERAL VIEW BILAT,5000118,CDM,320,RC,73620,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
XR FOOT AP/LATERAL VIEW LEFT,5000119,CDM,320,RC,73620,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
XR FOOT AP/LATERAL VIEW RIGHT,5000120,CDM,320,RC,73620,HCPCS,Outpatient,,,381,190.50,,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,259.08,68,,207.264,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,76.2,20,,60.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,247.65,65,,198.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,259.08,
XR HAND AP/LATERAL VIEW BILAT,5000121,CDM,320,RC,73120,HCPCS,Outpatient,,,341,170.50,,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,231.88,68,,185.504,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,231.88,
XR HAND AP/LATERAL VIEW LEFT,5000122,CDM,320,RC,73120,HCPCS,Outpatient,,,341,170.50,,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,231.88,68,,185.504,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,231.88,
XR HAND AP/LATERAL VIEW RIGHT,5000123,CDM,320,RC,73120,HCPCS,Outpatient,,,341,170.50,,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,231.88,68,,185.504,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,68.2,20,,54.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,221.65,65,,177.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,231.88,
XR CHEST AP (UPRIGHT) VIEW,5000124,CDM,324,RC,71045,HCPCS,Outpatient,,,335,167.50,,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,227.8,68,,182.24,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,227.8,
XR CHEST PA/LATERAL VIEW ROUTINE,5000125,CDM,324,RC,71046,HCPCS,Outpatient,,,77.25,38.63,,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,52.53,68,,42.024,Percent of Total Billed Charges,68% of Total Billed Charges,20.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,15.45,20,,12.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,50.21,65,,40.168,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.45,180,
XR DECUB CHEST,5000126,CDM,324,RC,71046,HCPCS,Outpatient,,,151.41,75.71,,98.42,65,,78.736,Percent of Total Billed Charges,65% of Total Billed Charges,102.96,68,,82.368,Percent of Total Billed Charges,68% of Total Billed Charges,20.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.28,20,,24.224,Percent of Total Billed Charges,20% of Total Billed Charges,30.28,20,,24.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.28,20,,24.224,Percent of Total Billed Charges,20% of Total Billed Charges,30.28,20,,24.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.42,65,,78.736,Percent of Total Billed Charges,65% of Total Billed Charges,98.42,65,,78.736,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.37,180,
XR CHEST PA HEALTH DEPT,5000127,CDM,324,RC,71010,HCPCS,Outpatient,,,56.67,28.34,,36.84,65,,29.472,Percent of Total Billed Charges,65% of Total Billed Charges,38.54,68,,30.832,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,11.33,20,,9.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.84,65,,29.472,Percent of Total Billed Charges,65% of Total Billed Charges,36.84,65,,29.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.33,180,
XR CHEST APICAL LORDOTIC VIEW,5000128,CDM,324,RC,71045,HCPCS,Outpatient,,,335,167.50,,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,227.8,68,,182.24,Percent of Total Billed Charges,68% of Total Billed Charges,15.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,67,20,,53.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,217.75,65,,174.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,227.8,
XR CD FOR PATIENT,5000129,CDM,999,RC,76499,HCPCS,Outpatient,,,7.21,3.61,,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.9,68,,3.92,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,1.44,20,,1.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,4.69,65,,3.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,4.9,
XR G-TUBE PATENCY CK,5000130,CDM,361,RC,49465,HCPCS,Outpatient,,,309,154.50,,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,210.12,68,,168.096,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,210.12,
CYSTOGRAM INJECTION,5000131,CDM,361,RC,51600,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,312,
FISTULAGRAM INJ,5000132,CDM,361,RC,76080,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,35.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.25,50,,61.8,Percent of Total Billed Charges,50% of Total Billed Charges,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,105.06,
XR T TUBE CHOLE INJECTION,5000133,CDM,361,RC,47531,HCPCS,Outpatient,,,162.23,81.12,,105.45,65,,84.36,Percent of Total Billed Charges,65% of Total Billed Charges,110.32,68,,88.256,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.45,20,,25.96,Percent of Total Billed Charges,20% of Total Billed Charges,32.45,20,,25.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.45,20,,25.96,Percent of Total Billed Charges,20% of Total Billed Charges,32.45,20,,25.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.45,65,,84.36,Percent of Total Billed Charges,65% of Total Billed Charges,105.45,65,,84.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2069,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.45,2069,
VOID CYSTO INJ,5000134,CDM,361,RC,51600,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,312,
CAD SCREENING,5000171,CDM,403,RC,77052,HCPCS,Outpatient,,,123.6,61.80,,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,84.05,68,,67.24,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,91,
LOCM 300-399MG/ML IOD 1ML,5000175,CDM,636,RC,Q9967,HCPCS,Outpatient,,,3.09,1.55,,2.01,65,,1.608,Percent of Total Billed Charges,65% of Total Billed Charges,2.1,68,,1.68,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,80,,1.976,Percent of Total Billed Charges,80% of Total Billed Charges,2.63,85,,2.104,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,2.63,
NG TUBE PLACEMENT,5000190,CDM,361,RC,43752,HCPCS,Outpatient,,,178.94,89.47,,116.31,65,,93.048,Percent of Total Billed Charges,65% of Total Billed Charges,121.68,68,,97.344,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,20,,28.632,Percent of Total Billed Charges,20% of Total Billed Charges,35.79,20,,28.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,20,,28.632,Percent of Total Billed Charges,20% of Total Billed Charges,35.79,20,,28.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.31,65,,93.048,Percent of Total Billed Charges,65% of Total Billed Charges,116.31,65,,93.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,178,
KOH FOR FUNGI/PARAS/MITES,5000193,CDM,306,RC,87220,HCPCS,Outpatient,,,10.3,5.15,,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,7,68,,5.6,Percent of Total Billed Charges,68% of Total Billed Charges,6.06,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,2.06,20,,1.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,6.7,65,,5.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,7,
XR SCOLIOSIS SERIES,5000195,CDM,320,RC,72082,HCPCS,Outpatient,,,336.26,168.13,,218.57,65,,174.856,Percent of Total Billed Charges,65% of Total Billed Charges,228.66,68,,182.928,Percent of Total Billed Charges,68% of Total Billed Charges,24.56,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,67.25,20,,53.8,Percent of Total Billed Charges,20% of Total Billed Charges,67.25,20,,53.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.25,20,,53.8,Percent of Total Billed Charges,20% of Total Billed Charges,67.25,20,,53.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.57,65,,174.856,Percent of Total Billed Charges,65% of Total Billed Charges,218.57,65,,174.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.56,228.66,
X-RAY NECK SPINE 4+ VIEW,5000196,CDM,320,RC,72050,HCPCS,Outpatient,,,309,154.50,,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,210.12,68,,168.096,Percent of Total Billed Charges,68% of Total Billed Charges,30.04,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.04,210.12,
X-RAY SI JOINTS 3+ VIEWS,5000197,CDM,320,RC,72202,HCPCS,Outpatient,,,273.98,136.99,,178.09,65,,142.472,Percent of Total Billed Charges,65% of Total Billed Charges,186.31,68,,149.048,Percent of Total Billed Charges,68% of Total Billed Charges,20.77,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,54.8,20,,43.84,Percent of Total Billed Charges,20% of Total Billed Charges,54.8,20,,43.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.8,20,,43.84,Percent of Total Billed Charges,20% of Total Billed Charges,54.8,20,,43.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.09,65,,142.472,Percent of Total Billed Charges,65% of Total Billed Charges,178.09,65,,142.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,186.31,
X-RAY PELV & HIPS 2+ VIEW,5000198,CDM,320,RC,73521,HCPCS,Outpatient,,,206,103.00,,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,140.08,68,,112.064,Percent of Total Billed Charges,68% of Total Billed Charges,22.37,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.37,180,
XR LEG INFANTS 2V,5000199,CDM,320,RC,73592,HCPCS,Outpatient,,,206,103.00,,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,140.08,68,,112.064,Percent of Total Billed Charges,68% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,180,
XR ESOPHAGRAM,5000200,CDM,320,RC,74220,HCPCS,Outpatient,,,93.85,46.93,,61,65,,48.8,Percent of Total Billed Charges,65% of Total Billed Charges,63.82,68,,51.056,Percent of Total Billed Charges,68% of Total Billed Charges,39.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.77,20,,15.016,Percent of Total Billed Charges,20% of Total Billed Charges,18.77,20,,15.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.77,20,,15.016,Percent of Total Billed Charges,20% of Total Billed Charges,18.77,20,,15.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61,65,,48.8,Percent of Total Billed Charges,65% of Total Billed Charges,61,65,,48.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.77,180,
XR UGI W KUB,5000201,CDM,320,RC,74240,HCPCS,Outpatient,,,519.12,259.56,,337.43,65,,269.944,Percent of Total Billed Charges,65% of Total Billed Charges,353,68,,282.4,Percent of Total Billed Charges,68% of Total Billed Charges,48.73,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,103.82,20,,83.056,Percent of Total Billed Charges,20% of Total Billed Charges,103.82,20,,83.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.82,20,,83.056,Percent of Total Billed Charges,20% of Total Billed Charges,103.82,20,,83.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,337.43,65,,269.944,Percent of Total Billed Charges,65% of Total Billed Charges,337.43,65,,269.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.73,353,
XR UGI W SM B,5000202,CDM,320,RC,,,Outpatient,,,178.94,89.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,20,,28.632,Percent of Total Billed Charges,20% of Total Billed Charges,35.79,20,,28.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,20,,28.632,Percent of Total Billed Charges,20% of Total Billed Charges,35.79,20,,28.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.31,65,,93.048,Percent of Total Billed Charges,65% of Total Billed Charges,116.31,65,,93.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,180,
XR UGI W AIR W KUB,5000203,CDM,320,RC,,,Outpatient,,,519.12,259.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.82,20,,83.056,Percent of Total Billed Charges,20% of Total Billed Charges,103.82,20,,83.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.82,20,,83.056,Percent of Total Billed Charges,20% of Total Billed Charges,103.82,20,,83.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,337.43,65,,269.944,Percent of Total Billed Charges,65% of Total Billed Charges,337.43,65,,269.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,337.43,
COLN SCN BE ALT TO CNSPY,5000204,CDM,320,RC,G0120,HCPCS,Outpatient,,,327.83,163.92,,213.09,65,,170.472,Percent of Total Billed Charges,65% of Total Billed Charges,222.92,68,,178.336,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.57,20,,52.456,Percent of Total Billed Charges,20% of Total Billed Charges,65.57,20,,52.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.57,20,,52.456,Percent of Total Billed Charges,20% of Total Billed Charges,65.57,20,,52.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.09,65,,170.472,Percent of Total Billed Charges,65% of Total Billed Charges,213.09,65,,170.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,222.92,
X-RAY RIBS 3 VIEWS BILAT,5000205,CDM,324,RC,71110,HCPCS,Outpatient,,,300,150.00,,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,26.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.36,204,
CAROTID DUPLEX SCAN UNIL  LEFT,5000224,CDM,921,RC,93882,HCPCS,Outpatient,,,772.5,386.25,,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,525.3,68,,420.24,Percent of Total Billed Charges,68% of Total Billed Charges,87.87,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,525.3,
MRI BRAIN W/O CONTRAST,5000300,CDM,611,RC,70551,HCPCS,Outpatient,,,1339,669.50,,870.35,65,,696.28,Percent of Total Billed Charges,65% of Total Billed Charges,910.52,68,,728.416,Percent of Total Billed Charges,68% of Total Billed Charges,373.36,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,267.8,20,,214.24,Percent of Total Billed Charges,20% of Total Billed Charges,267.8,20,,214.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.8,20,,214.24,Percent of Total Billed Charges,20% of Total Billed Charges,267.8,20,,214.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,870.35,65,,696.28,Percent of Total Billed Charges,65% of Total Billed Charges,870.35,65,,696.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,739,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,910.52,
CAROTID DUPLEX SCAN UNIL RIGHT,5010224,CDM,921,RC,93882,HCPCS,Outpatient,,,772.5,386.25,,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,525.3,68,,420.24,Percent of Total Billed Charges,68% of Total Billed Charges,87.87,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,525.3,
=>CANCEL RADIOLOGY ORDER<=,5090001,CDM,320,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,180,
BACT CULT QUAN AEROBIC,5099997,CDM,306,RC,87071,HCPCS,Outpatient,,,15.45,7.73,,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.51,68,,8.408,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,3.09,20,,2.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,10.04,65,,8.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,50,,6.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,10.51,
US GALLBLADDER,5100141,CDM,402,RC,76705,HCPCS,Outpatient,,,854,427.00,,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,580.72,68,,464.576,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,580.72,
US RENAL LEFT,5100142,CDM,402,RC,76775,HCPCS,Outpatient,,,515,257.50,,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,350.2,68,,280.16,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,350.2,
US ABDOMINAL AORTA,5100143,CDM,402,RC,76706,HCPCS,Outpatient,,,854,427.00,,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,580.72,68,,464.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,580.72,
US PELVIS COMPLETE,5100144,CDM,402,RC,76856,HCPCS,Outpatient,,,850,425.00,,552.5,65,,442,Percent of Total Billed Charges,65% of Total Billed Charges,578,68,,462.4,Percent of Total Billed Charges,68% of Total Billed Charges,51.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,170,20,,136,Percent of Total Billed Charges,20% of Total Billed Charges,170,20,,136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170,20,,136,Percent of Total Billed Charges,20% of Total Billed Charges,170,20,,136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,552.5,65,,442,Percent of Total Billed Charges,65% of Total Billed Charges,552.5,65,,442,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.12,578,
US SINGLE ORGAN,5100145,CDM,402,RC,76705,HCPCS,Outpatient,,,854,427.00,,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,580.72,68,,464.576,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,580.72,
US TRANSRECTAL,5100146,CDM,402,RC,76872,HCPCS,Outpatient,,,783,391.50,,508.95,65,,407.16,Percent of Total Billed Charges,65% of Total Billed Charges,532.44,68,,425.952,Percent of Total Billed Charges,68% of Total Billed Charges,51.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,156.6,20,,125.28,Percent of Total Billed Charges,20% of Total Billed Charges,156.6,20,,125.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.6,20,,125.28,Percent of Total Billed Charges,20% of Total Billed Charges,156.6,20,,125.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,508.95,65,,407.16,Percent of Total Billed Charges,65% of Total Billed Charges,508.95,65,,407.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.12,532.44,
US SCROTUM BILATERAL,5100147,CDM,402,RC,76870,HCPCS,Outpatient,,,716,358.00,,465.4,65,,372.32,Percent of Total Billed Charges,65% of Total Billed Charges,486.88,68,,389.504,Percent of Total Billed Charges,68% of Total Billed Charges,51.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,143.2,20,,114.56,Percent of Total Billed Charges,20% of Total Billed Charges,143.2,20,,114.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.2,20,,114.56,Percent of Total Billed Charges,20% of Total Billed Charges,143.2,20,,114.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.4,65,,372.32,Percent of Total Billed Charges,65% of Total Billed Charges,465.4,65,,372.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.12,486.88,
US PREG UTER>14 WKS SNG,5100148,CDM,402,RC,76805,HCPCS,Outpatient,,,994,497.00,,646.1,65,,516.88,Percent of Total Billed Charges,65% of Total Billed Charges,675.92,68,,540.736,Percent of Total Billed Charges,68% of Total Billed Charges,70.13,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,198.8,20,,159.04,Percent of Total Billed Charges,20% of Total Billed Charges,198.8,20,,159.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.8,20,,159.04,Percent of Total Billed Charges,20% of Total Billed Charges,198.8,20,,159.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,646.1,65,,516.88,Percent of Total Billed Charges,65% of Total Billed Charges,646.1,65,,516.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,675.92,
US PREG UTER LTD,5100149,CDM,402,RC,76815,HCPCS,Outpatient,,,252.35,126.18,,164.03,65,,131.224,Percent of Total Billed Charges,65% of Total Billed Charges,171.6,68,,137.28,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,50.47,20,,40.376,Percent of Total Billed Charges,20% of Total Billed Charges,50.47,20,,40.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.47,20,,40.376,Percent of Total Billed Charges,20% of Total Billed Charges,50.47,20,,40.376,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.03,65,,131.224,Percent of Total Billed Charges,65% of Total Billed Charges,164.03,65,,131.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,180,
US BREAST LEFT,5100150,CDM,402,RC,76641,HCPCS,Outpatient,,,697,348.50,,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,473.96,68,,379.168,Percent of Total Billed Charges,68% of Total Billed Charges,35.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.31,473.96,
US THYROID COMPLETE,5100151,CDM,402,RC,76536,HCPCS,Outpatient,,,711,355.50,,462.15,65,,369.72,Percent of Total Billed Charges,65% of Total Billed Charges,483.48,68,,386.784,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,142.2,20,,113.76,Percent of Total Billed Charges,20% of Total Billed Charges,142.2,20,,113.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.2,20,,113.76,Percent of Total Billed Charges,20% of Total Billed Charges,142.2,20,,113.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,462.15,65,,369.72,Percent of Total Billed Charges,65% of Total Billed Charges,462.15,65,,369.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,483.48,
US BREAST RIGHT,5100152,CDM,402,RC,76641,HCPCS,Outpatient,,,697,348.50,,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,473.96,68,,379.168,Percent of Total Billed Charges,68% of Total Billed Charges,35.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.31,473.96,
US BREAST BILATERAL,5100153,CDM,402,RC,76641,HCPCS,Outpatient,,,697,348.50,,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,473.96,68,,379.168,Percent of Total Billed Charges,68% of Total Billed Charges,35.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,139.4,20,,111.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,453.05,65,,362.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.31,473.96,
US RENAL RIGHT,5100154,CDM,402,RC,76775,HCPCS,Outpatient,,,515,257.50,,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,350.2,68,,280.16,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,350.2,
US TRANSVAG NON PREG,5100155,CDM,402,RC,76830,HCPCS,Outpatient,,,618,309.00,,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,420.24,68,,336.192,Percent of Total Billed Charges,68% of Total Billed Charges,51.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.12,420.24,
US ABDOMEN COMPLETE,5100156,CDM,402,RC,76700,HCPCS,Outpatient,,,1056,528.00,,686.4,65,,549.12,Percent of Total Billed Charges,65% of Total Billed Charges,718.08,68,,574.464,Percent of Total Billed Charges,68% of Total Billed Charges,65.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,211.2,20,,168.96,Percent of Total Billed Charges,20% of Total Billed Charges,211.2,20,,168.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.2,20,,168.96,Percent of Total Billed Charges,20% of Total Billed Charges,211.2,20,,168.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,686.4,65,,549.12,Percent of Total Billed Charges,65% of Total Billed Charges,686.4,65,,549.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,718.08,
US EXTR NON VASC,5100157,CDM,402,RC,76881,HCPCS,Outpatient,,,371.62,185.81,,241.55,65,,193.24,Percent of Total Billed Charges,65% of Total Billed Charges,252.7,68,,202.16,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,74.32,20,,59.456,Percent of Total Billed Charges,20% of Total Billed Charges,74.32,20,,59.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.32,20,,59.456,Percent of Total Billed Charges,20% of Total Billed Charges,74.32,20,,59.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.55,65,,193.24,Percent of Total Billed Charges,65% of Total Billed Charges,241.55,65,,193.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,252.7,
US RENAL BILATERAL,5100158,CDM,402,RC,76770,HCPCS,Outpatient,,,1114,557.00,,724.1,65,,579.28,Percent of Total Billed Charges,65% of Total Billed Charges,757.52,68,,606.016,Percent of Total Billed Charges,68% of Total Billed Charges,65.82,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,222.8,20,,178.24,Percent of Total Billed Charges,20% of Total Billed Charges,222.8,20,,178.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.8,20,,178.24,Percent of Total Billed Charges,20% of Total Billed Charges,222.8,20,,178.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,724.1,65,,579.28,Percent of Total Billed Charges,65% of Total Billed Charges,724.1,65,,579.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,757.52,
US RUQ,5100159,CDM,402,RC,76705,HCPCS,Outpatient,,,854,427.00,,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,580.72,68,,464.576,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,170.8,20,,136.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,555.1,65,,444.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,580.72,
US NEO HEAD,5100160,CDM,402,RC,76506,HCPCS,Outpatient,,,954,477.00,,620.1,65,,496.08,Percent of Total Billed Charges,65% of Total Billed Charges,648.72,68,,518.976,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,190.8,20,,152.64,Percent of Total Billed Charges,20% of Total Billed Charges,190.8,20,,152.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.8,20,,152.64,Percent of Total Billed Charges,20% of Total Billed Charges,190.8,20,,152.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,620.1,65,,496.08,Percent of Total Billed Charges,65% of Total Billed Charges,620.1,65,,496.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,648.72,
US PREG TRANS VAG,5100161,CDM,402,RC,76817,HCPCS,Outpatient,,,736,368.00,,478.4,65,,382.72,Percent of Total Billed Charges,65% of Total Billed Charges,500.48,68,,400.384,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.2,20,,117.76,Percent of Total Billed Charges,20% of Total Billed Charges,147.2,20,,117.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.2,20,,117.76,Percent of Total Billed Charges,20% of Total Billed Charges,147.2,20,,117.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,478.4,65,,382.72,Percent of Total Billed Charges,65% of Total Billed Charges,478.4,65,,382.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,500.48,
US GUIDE/ASP/BX,5100162,CDM,402,RC,76942,HCPCS,Outpatient,,,789,394.50,,512.85,65,,410.28,Percent of Total Billed Charges,65% of Total Billed Charges,536.52,68,,429.216,Percent of Total Billed Charges,68% of Total Billed Charges,51.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,157.8,20,,126.24,Percent of Total Billed Charges,20% of Total Billed Charges,157.8,20,,126.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.8,20,,126.24,Percent of Total Billed Charges,20% of Total Billed Charges,157.8,20,,126.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,512.85,65,,410.28,Percent of Total Billed Charges,65% of Total Billed Charges,512.85,65,,410.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.12,536.52,
US CHEST B-SCAN,5100163,CDM,402,RC,76604,HCPCS,Outpatient,,,337.84,168.92,,219.6,65,,175.68,Percent of Total Billed Charges,65% of Total Billed Charges,229.73,68,,183.784,Percent of Total Billed Charges,68% of Total Billed Charges,43.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,67.57,20,,54.056,Percent of Total Billed Charges,20% of Total Billed Charges,67.57,20,,54.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.57,20,,54.056,Percent of Total Billed Charges,20% of Total Billed Charges,67.57,20,,54.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.6,65,,175.68,Percent of Total Billed Charges,65% of Total Billed Charges,219.6,65,,175.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.45,229.73,
US PREG DETAIL ADDL,5100164,CDM,402,RC,76812,HCPCS,Outpatient,,,429.51,214.76,,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,292.07,68,,233.656,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,292.07,
US PREG DETAIL SINGLE,5100165,CDM,402,RC,76811,HCPCS,Outpatient,,,475.86,237.93,,309.31,65,,247.448,Percent of Total Billed Charges,65% of Total Billed Charges,323.58,68,,258.864,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.17,20,,76.136,Percent of Total Billed Charges,20% of Total Billed Charges,95.17,20,,76.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.17,20,,76.136,Percent of Total Billed Charges,20% of Total Billed Charges,95.17,20,,76.136,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309.31,65,,247.448,Percent of Total Billed Charges,65% of Total Billed Charges,309.31,65,,247.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,323.58,
US PREG UTER<14 WK EA ADD,5100166,CDM,402,RC,76802,HCPCS,Outpatient,,,429.51,214.76,,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,292.07,68,,233.656,Percent of Total Billed Charges,68% of Total Billed Charges,70.13,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,292.07,
US PREG UTER<14 WK SINGLE,5100167,CDM,402,RC,76801,HCPCS,Outpatient,,,429.51,214.76,,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,292.07,68,,233.656,Percent of Total Billed Charges,68% of Total Billed Charges,70.13,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,292.07,
US PREG UTER>14 WK AD,5100168,CDM,402,RC,76810,HCPCS,Outpatient,,,429.51,214.76,,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,292.07,68,,233.656,Percent of Total Billed Charges,68% of Total Billed Charges,70.13,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,85.9,20,,68.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,279.18,65,,223.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,292.07,
US HEAD AND NECK,5100169,CDM,402,RC,76536,HCPCS,Outpatient,,,711,355.50,,462.15,65,,369.72,Percent of Total Billed Charges,65% of Total Billed Charges,483.48,68,,386.784,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,142.2,20,,113.76,Percent of Total Billed Charges,20% of Total Billed Charges,142.2,20,,113.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.2,20,,113.76,Percent of Total Billed Charges,20% of Total Billed Charges,142.2,20,,113.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,462.15,65,,369.72,Percent of Total Billed Charges,65% of Total Billed Charges,462.15,65,,369.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,483.48,
US ECHOCARDIOGRAM,5100172,CDM,480,RC,93307,HCPCS,Outpatient,,,1854,927.00,,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,1260.72,68,,1008.576,Percent of Total Billed Charges,68% of Total Billed Charges,130.53,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,370.8,20,,296.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,1205.1,65,,964.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,591,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1260.72,
US VENOUS EXTR LEFT,5100176,CDM,402,RC,93971,HCPCS,Outpatient,,,1004.25,502.13,,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,682.89,68,,546.312,Percent of Total Billed Charges,68% of Total Billed Charges,98.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,682.89,
US CAROTID BILATERAL,5100177,CDM,921,RC,93880,HCPCS,Outpatient,,,1545,772.50,,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,1050.6,68,,840.48,Percent of Total Billed Charges,68% of Total Billed Charges,132.61,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1050.6,
US LOW EXTR ART LEFT,5100178,CDM,921,RC,93926,HCPCS,Outpatient,,,395.52,197.76,,257.09,65,,205.672,Percent of Total Billed Charges,65% of Total Billed Charges,268.95,68,,215.16,Percent of Total Billed Charges,68% of Total Billed Charges,88.99,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,79.1,20,,63.28,Percent of Total Billed Charges,20% of Total Billed Charges,79.1,20,,63.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.1,20,,63.28,Percent of Total Billed Charges,20% of Total Billed Charges,79.1,20,,63.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.09,65,,205.672,Percent of Total Billed Charges,65% of Total Billed Charges,257.09,65,,205.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,268.95,
US DOPPLER AORTA,5100180,CDM,921,RC,93978,HCPCS,Outpatient,,,428.48,214.24,,278.51,65,,222.808,Percent of Total Billed Charges,65% of Total Billed Charges,291.37,68,,233.096,Percent of Total Billed Charges,68% of Total Billed Charges,137.4,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,85.7,20,,68.56,Percent of Total Billed Charges,20% of Total Billed Charges,85.7,20,,68.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.7,20,,68.56,Percent of Total Billed Charges,20% of Total Billed Charges,85.7,20,,68.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.51,65,,222.808,Percent of Total Billed Charges,65% of Total Billed Charges,278.51,65,,222.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,291.37,
US UPPER EXT ART LEFT,5100181,CDM,921,RC,93931,HCPCS,Outpatient,,,327.54,163.77,,212.9,65,,170.32,Percent of Total Billed Charges,65% of Total Billed Charges,222.73,68,,178.184,Percent of Total Billed Charges,68% of Total Billed Charges,93,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,65.51,20,,52.408,Percent of Total Billed Charges,20% of Total Billed Charges,65.51,20,,52.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.51,20,,52.408,Percent of Total Billed Charges,20% of Total Billed Charges,65.51,20,,52.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.9,65,,170.32,Percent of Total Billed Charges,65% of Total Billed Charges,212.9,65,,170.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,222.73,
US LOW EXTR ART RIGHT,5100182,CDM,921,RC,93926,HCPCS,Outpatient,,,435.07,217.54,,282.8,65,,226.24,Percent of Total Billed Charges,65% of Total Billed Charges,295.85,68,,236.68,Percent of Total Billed Charges,68% of Total Billed Charges,88.99,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,87.01,20,,69.608,Percent of Total Billed Charges,20% of Total Billed Charges,87.01,20,,69.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.01,20,,69.608,Percent of Total Billed Charges,20% of Total Billed Charges,87.01,20,,69.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.8,65,,226.24,Percent of Total Billed Charges,65% of Total Billed Charges,282.8,65,,226.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,295.85,
US LOW EXTR ART BILATERAL,5100183,CDM,921,RC,93925,HCPCS,Outpatient,,,1004.25,502.13,,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,682.89,68,,546.312,Percent of Total Billed Charges,68% of Total Billed Charges,133.25,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,682.89,
US VENOUS EXTR RIGHT,5100184,CDM,921,RC,93971,HCPCS,Outpatient,,,1004.25,502.13,,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,682.89,68,,546.312,Percent of Total Billed Charges,68% of Total Billed Charges,98.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,682.89,
US UPPER EXT ART RIGHT,5100185,CDM,921,RC,93931,HCPCS,Outpatient,,,327.54,163.77,,212.9,65,,170.32,Percent of Total Billed Charges,65% of Total Billed Charges,222.73,68,,178.184,Percent of Total Billed Charges,68% of Total Billed Charges,93,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,65.51,20,,52.408,Percent of Total Billed Charges,20% of Total Billed Charges,65.51,20,,52.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.51,20,,52.408,Percent of Total Billed Charges,20% of Total Billed Charges,65.51,20,,52.408,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.9,65,,170.32,Percent of Total Billed Charges,65% of Total Billed Charges,212.9,65,,170.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,222.73,
US VENOUS EXTR BILATERAL,5100186,CDM,921,RC,93970,HCPCS,Outpatient,,,1055.75,527.88,,686.24,65,,548.992,Percent of Total Billed Charges,65% of Total Billed Charges,717.91,68,,574.328,Percent of Total Billed Charges,68% of Total Billed Charges,147.62,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,211.15,20,,168.92,Percent of Total Billed Charges,20% of Total Billed Charges,211.15,20,,168.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.15,20,,168.92,Percent of Total Billed Charges,20% of Total Billed Charges,211.15,20,,168.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,686.24,65,,548.992,Percent of Total Billed Charges,65% of Total Billed Charges,686.24,65,,548.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,717.91,
US UPPER EXT ART BILATERAL,5100187,CDM,921,RC,93930,HCPCS,Outpatient,,,794.13,397.07,,516.18,65,,412.944,Percent of Total Billed Charges,65% of Total Billed Charges,540.01,68,,432.008,Percent of Total Billed Charges,68% of Total Billed Charges,141.23,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,158.83,20,,127.064,Percent of Total Billed Charges,20% of Total Billed Charges,158.83,20,,127.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.83,20,,127.064,Percent of Total Billed Charges,20% of Total Billed Charges,158.83,20,,127.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.18,65,,412.944,Percent of Total Billed Charges,65% of Total Billed Charges,516.18,65,,412.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,540.01,
US ABD + FLOW,5100188,CDM,921,RC,93975,HCPCS,Outpatient,,,618,309.00,,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,420.24,68,,336.192,Percent of Total Billed Charges,68% of Total Billed Charges,167.12,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,420.24,
US VENOUS EXTREM LEFT,5100189,CDM,921,RC,93971,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,98.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,98.58,
US XTR NON-VASC COMPLETE,5100206,CDM,402,RC,76881,HCPCS,Outpatient,,,606,303.00,,393.9,65,,315.12,Percent of Total Billed Charges,65% of Total Billed Charges,412.08,68,,329.664,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,121.2,20,,96.96,Percent of Total Billed Charges,20% of Total Billed Charges,121.2,20,,96.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.2,20,,96.96,Percent of Total Billed Charges,20% of Total Billed Charges,121.2,20,,96.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,393.9,65,,315.12,Percent of Total Billed Charges,65% of Total Billed Charges,393.9,65,,315.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,412.08,
US EXTR NON-VAS LTD,5100207,CDM,402,RC,76882,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,180,
US AAA SCREEN,5100208,CDM,402,RC,76706,HCPCS,Outpatient,,,167.79,83.90,,109.06,65,,87.248,Percent of Total Billed Charges,65% of Total Billed Charges,114.1,68,,91.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.56,20,,26.848,Percent of Total Billed Charges,20% of Total Billed Charges,33.56,20,,26.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.56,20,,26.848,Percent of Total Billed Charges,20% of Total Billed Charges,33.56,20,,26.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.06,65,,87.248,Percent of Total Billed Charges,65% of Total Billed Charges,109.06,65,,87.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.56,180,
US INFANT HIPS,5100222,CDM,402,RC,76886,HCPCS,Outpatient,,,272.95,136.48,,177.42,65,,141.936,Percent of Total Billed Charges,65% of Total Billed Charges,185.61,68,,148.488,Percent of Total Billed Charges,68% of Total Billed Charges,51.38,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,54.59,20,,43.672,Percent of Total Billed Charges,20% of Total Billed Charges,54.59,20,,43.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.59,20,,43.672,Percent of Total Billed Charges,20% of Total Billed Charges,54.59,20,,43.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.42,65,,141.936,Percent of Total Billed Charges,65% of Total Billed Charges,177.42,65,,141.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.38,185.61,
US SOFT TISSUE HEAD AND NECK,5100223,CDM,402,RC,76536,HCPCS,Outpatient,,,337.84,168.92,,219.6,65,,175.68,Percent of Total Billed Charges,65% of Total Billed Charges,229.73,68,,183.784,Percent of Total Billed Charges,68% of Total Billed Charges,47.45,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,67.57,20,,54.056,Percent of Total Billed Charges,20% of Total Billed Charges,67.57,20,,54.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.57,20,,54.056,Percent of Total Billed Charges,20% of Total Billed Charges,67.57,20,,54.056,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.6,65,,175.68,Percent of Total Billed Charges,65% of Total Billed Charges,219.6,65,,175.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.45,229.73,
US INTRAVASCULAR,5100301,CDM,402,RC,76937,HCPCS,Outpatient,,,595.34,297.67,,386.97,65,,309.576,Percent of Total Billed Charges,65% of Total Billed Charges,404.83,68,,323.864,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.07,20,,95.256,Percent of Total Billed Charges,20% of Total Billed Charges,119.07,20,,95.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.07,20,,95.256,Percent of Total Billed Charges,20% of Total Billed Charges,119.07,20,,95.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.97,65,,309.576,Percent of Total Billed Charges,65% of Total Billed Charges,386.97,65,,309.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,404.83,
US BLADDER ONLY POST VOID,5100302,CDM,402,RC,51798,HCPCS,Outpatient,,,203.8,101.90,,132.47,65,,105.976,Percent of Total Billed Charges,65% of Total Billed Charges,138.58,68,,110.864,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.76,20,,32.608,Percent of Total Billed Charges,20% of Total Billed Charges,40.76,20,,32.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.76,20,,32.608,Percent of Total Billed Charges,20% of Total Billed Charges,40.76,20,,32.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.47,65,,105.976,Percent of Total Billed Charges,65% of Total Billed Charges,132.47,65,,105.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.76,178,
US PELVIS SOFT TISSUE,5100303,CDM,402,RC,76857,HCPCS,Outpatient,,,572,286.00,,371.8,65,,297.44,Percent of Total Billed Charges,65% of Total Billed Charges,388.96,68,,311.168,Percent of Total Billed Charges,68% of Total Billed Charges,35.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,114.4,20,,91.52,Percent of Total Billed Charges,20% of Total Billed Charges,114.4,20,,91.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.4,20,,91.52,Percent of Total Billed Charges,20% of Total Billed Charges,114.4,20,,91.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.8,65,,297.44,Percent of Total Billed Charges,65% of Total Billed Charges,371.8,65,,297.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.31,388.96,
US VENOUS EXTREM RIGHT,5110189,CDM,921,RC,93971,HCPCS,Outpatient,,,684.95,342.48,,445.22,65,,356.176,Percent of Total Billed Charges,65% of Total Billed Charges,465.77,68,,372.616,Percent of Total Billed Charges,68% of Total Billed Charges,98.58,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,136.99,20,,109.592,Percent of Total Billed Charges,20% of Total Billed Charges,136.99,20,,109.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.99,20,,109.592,Percent of Total Billed Charges,20% of Total Billed Charges,136.99,20,,109.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.22,65,,356.176,Percent of Total Billed Charges,65% of Total Billed Charges,445.22,65,,356.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,465.77,
US VASC NEEDLE GUIDE,5110301,CDM,402,RC,76937,HCPCS,Outpatient,,,595.34,297.67,,386.97,65,,309.576,Percent of Total Billed Charges,65% of Total Billed Charges,404.83,68,,323.864,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.07,20,,95.256,Percent of Total Billed Charges,20% of Total Billed Charges,119.07,20,,95.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.07,20,,95.256,Percent of Total Billed Charges,20% of Total Billed Charges,119.07,20,,95.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.97,65,,309.576,Percent of Total Billed Charges,65% of Total Billed Charges,386.97,65,,309.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,404.83,
US PELVIC LTD NON OB,5110303,CDM,402,RC,76857,HCPCS,Outpatient,,,223,111.50,,144.95,65,,115.96,Percent of Total Billed Charges,65% of Total Billed Charges,151.64,68,,121.312,Percent of Total Billed Charges,68% of Total Billed Charges,35.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,44.6,20,,35.68,Percent of Total Billed Charges,20% of Total Billed Charges,44.6,20,,35.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.6,20,,35.68,Percent of Total Billed Charges,20% of Total Billed Charges,44.6,20,,35.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.95,65,,115.96,Percent of Total Billed Charges,65% of Total Billed Charges,144.95,65,,115.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.31,180,
CT ABD & PELV W/O CON,5200211,CDM,350,RC,74176,HCPCS,Outpatient,,,2709,1354.50,,1760.85,65,,1408.68,Percent of Total Billed Charges,65% of Total Billed Charges,1842.12,68,,1473.696,Percent of Total Billed Charges,68% of Total Billed Charges,386.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,541.8,20,,433.44,Percent of Total Billed Charges,20% of Total Billed Charges,541.8,20,,433.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,541.8,20,,433.44,Percent of Total Billed Charges,20% of Total Billed Charges,541.8,20,,433.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1760.85,65,,1408.68,Percent of Total Billed Charges,65% of Total Billed Charges,1760.85,65,,1408.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1842.12,
CT ABD & PELV 1+ SEC/REG,5200213,CDM,972,RC,74178,HCPCS,Outpatient,,,666.41,333.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,367.55,110,,,Fee Schedule,110% of Multiplan Fee Schedule,367.55,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,422.69,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,244.55,100,,,Case Rate,Pays Based on per visit rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid rate,191.95,422.69,
CT LOWER LEG LEFT,5210075,CDM,352,RC,73700,HCPCS,Outpatient,,,1677,838.50,,1090.05,65,,872.04,Percent of Total Billed Charges,65% of Total Billed Charges,1140.36,68,,912.288,Percent of Total Billed Charges,68% of Total Billed Charges,165.51,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,335.4,20,,268.32,Percent of Total Billed Charges,20% of Total Billed Charges,335.4,20,,268.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.4,20,,268.32,Percent of Total Billed Charges,20% of Total Billed Charges,335.4,20,,268.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1090.05,65,,872.04,Percent of Total Billed Charges,65% of Total Billed Charges,1090.05,65,,872.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1140.36,
CT CHEST (UNSPECIFIED) LOW DOSE,5210086,CDM,352,RC,71271,HCPCS,Outpatient,,,2678,1339.00,,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,1821.04,68,,1456.832,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1821.04,
GASTROVIEW/BOTTLE,5220001,CDM,250,RC,,,Outpatient,,,76.22,38.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,15.24,20,,12.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,49.54,65,,39.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.24,53.67,
BARIUM/BOTTLE 50ML,5220003,CDM,250,RC,,,Outpatient,,,16.48,8.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,3.3,20,,2.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,10.71,65,,8.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.3,53.67,
CT LIMITED,5220005,CDM,350,RC,76380,HCPCS,Outpatient,,,666.41,333.21,,433.17,65,,346.536,Percent of Total Billed Charges,65% of Total Billed Charges,453.16,68,,362.528,Percent of Total Billed Charges,68% of Total Billed Charges,116.78,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,133.28,20,,106.624,Percent of Total Billed Charges,20% of Total Billed Charges,133.28,20,,106.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.28,20,,106.624,Percent of Total Billed Charges,20% of Total Billed Charges,133.28,20,,106.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,433.17,65,,346.536,Percent of Total Billed Charges,65% of Total Billed Charges,433.17,65,,346.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,453.16,
CT BRAIN W/ CONTRAST,5220007,CDM,351,RC,70460,HCPCS,Outpatient,,,3296,1648.00,,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,2241.28,68,,1793.024,Percent of Total Billed Charges,68% of Total Billed Charges,189,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2241.28,
CT BRAIN W/WO CONTRAST,5220009,CDM,351,RC,70470,HCPCS,Outpatient,,,3296,1648.00,,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,2241.28,68,,1793.024,Percent of Total Billed Charges,68% of Total Billed Charges,235.97,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2241.28,
CT BRAIN W/O CONTRAST,5220011,CDM,351,RC,70450,HCPCS,Outpatient,,,3069,1534.50,,1994.85,65,,1595.88,Percent of Total Billed Charges,65% of Total Billed Charges,2086.92,68,,1669.536,Percent of Total Billed Charges,68% of Total Billed Charges,157.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,613.8,20,,491.04,Percent of Total Billed Charges,20% of Total Billed Charges,613.8,20,,491.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,613.8,20,,491.04,Percent of Total Billed Charges,20% of Total Billed Charges,613.8,20,,491.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1994.85,65,,1595.88,Percent of Total Billed Charges,65% of Total Billed Charges,1994.85,65,,1595.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2086.92,
CT FACIAL W/O CONTRAST,5220013,CDM,351,RC,70486,HCPCS,Outpatient,,,824,412.00,,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,560.32,68,,448.256,Percent of Total Billed Charges,68% of Total Billed Charges,157.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,164.8,20,,131.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,535.6,65,,428.48,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,560.32,
CT NECK W/ CONTRAST,5220017,CDM,351,RC,70491,HCPCS,Outpatient,,,2781,1390.50,,1807.65,65,,1446.12,Percent of Total Billed Charges,65% of Total Billed Charges,1891.08,68,,1512.864,Percent of Total Billed Charges,68% of Total Billed Charges,189,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,556.2,20,,444.96,Percent of Total Billed Charges,20% of Total Billed Charges,556.2,20,,444.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,556.2,20,,444.96,Percent of Total Billed Charges,20% of Total Billed Charges,556.2,20,,444.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1807.65,65,,1446.12,Percent of Total Billed Charges,65% of Total Billed Charges,1807.65,65,,1446.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1891.08,
CT NECK W/WO CONTRAST,5220019,CDM,351,RC,70492,HCPCS,Outpatient,,,3053,1526.50,,1984.45,65,,1587.56,Percent of Total Billed Charges,65% of Total Billed Charges,2076.04,68,,1660.832,Percent of Total Billed Charges,68% of Total Billed Charges,235.97,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,610.6,20,,488.48,Percent of Total Billed Charges,20% of Total Billed Charges,610.6,20,,488.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,610.6,20,,488.48,Percent of Total Billed Charges,20% of Total Billed Charges,610.6,20,,488.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1984.45,65,,1587.56,Percent of Total Billed Charges,65% of Total Billed Charges,1984.45,65,,1587.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2076.04,
CT NECK W/O CONTRAST,5220021,CDM,351,RC,70490,HCPCS,Outpatient,,,772.5,386.25,,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,525.3,68,,420.24,Percent of Total Billed Charges,68% of Total Billed Charges,157.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,154.5,20,,123.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,502.13,65,,401.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,525.3,
CT ORBITS IAC W/ CONTRAST,5220023,CDM,351,RC,70481,HCPCS,Outpatient,,,2997,1498.50,,1948.05,65,,1558.44,Percent of Total Billed Charges,65% of Total Billed Charges,2037.96,68,,1630.368,Percent of Total Billed Charges,68% of Total Billed Charges,189,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,599.4,20,,479.52,Percent of Total Billed Charges,20% of Total Billed Charges,599.4,20,,479.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,599.4,20,,479.52,Percent of Total Billed Charges,20% of Total Billed Charges,599.4,20,,479.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1948.05,65,,1558.44,Percent of Total Billed Charges,65% of Total Billed Charges,1948.05,65,,1558.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2037.96,
CT ORBITS IAC W/O CONTRAST,5220025,CDM,351,RC,70480,HCPCS,Outpatient,,,2781,1390.50,,1807.65,65,,1446.12,Percent of Total Billed Charges,65% of Total Billed Charges,1891.08,68,,1512.864,Percent of Total Billed Charges,68% of Total Billed Charges,157.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,556.2,20,,444.96,Percent of Total Billed Charges,20% of Total Billed Charges,556.2,20,,444.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,556.2,20,,444.96,Percent of Total Billed Charges,20% of Total Billed Charges,556.2,20,,444.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1807.65,65,,1446.12,Percent of Total Billed Charges,65% of Total Billed Charges,1807.65,65,,1446.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1891.08,
CT SINUS WI/ CONTRAS,5220027,CDM,351,RC,70487,HCPCS,Outpatient,,,2540,1270.00,,1651,65,,1320.8,Percent of Total Billed Charges,65% of Total Billed Charges,1727.2,68,,1381.76,Percent of Total Billed Charges,68% of Total Billed Charges,189,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,508,20,,406.4,Percent of Total Billed Charges,20% of Total Billed Charges,508,20,,406.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,508,20,,406.4,Percent of Total Billed Charges,20% of Total Billed Charges,508,20,,406.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1651,65,,1320.8,Percent of Total Billed Charges,65% of Total Billed Charges,1651,65,,1320.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1727.2,
CT SINUS W/O CONTRAST,5220029,CDM,351,RC,70486,HCPCS,Outpatient,,,2852,1426.00,,1853.8,65,,1483.04,Percent of Total Billed Charges,65% of Total Billed Charges,1939.36,68,,1551.488,Percent of Total Billed Charges,68% of Total Billed Charges,157.68,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,570.4,20,,456.32,Percent of Total Billed Charges,20% of Total Billed Charges,570.4,20,,456.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,570.4,20,,456.32,Percent of Total Billed Charges,20% of Total Billed Charges,570.4,20,,456.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1853.8,65,,1483.04,Percent of Total Billed Charges,65% of Total Billed Charges,1853.8,65,,1483.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1939.36,
CT FACIAL W/WO CONTRAST,5220031,CDM,351,RC,70488,HCPCS,Outpatient,,,2852,1426.00,,1853.8,65,,1483.04,Percent of Total Billed Charges,65% of Total Billed Charges,1939.36,68,,1551.488,Percent of Total Billed Charges,68% of Total Billed Charges,235.97,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,570.4,20,,456.32,Percent of Total Billed Charges,20% of Total Billed Charges,570.4,20,,456.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,570.4,20,,456.32,Percent of Total Billed Charges,20% of Total Billed Charges,570.4,20,,456.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1853.8,65,,1483.04,Percent of Total Billed Charges,65% of Total Billed Charges,1853.8,65,,1483.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1939.36,
CT ABDOMEN W/ CONTRAST,5220035,CDM,352,RC,74160,HCPCS,Outpatient,,,2735,1367.50,,1777.75,65,,1422.2,Percent of Total Billed Charges,65% of Total Billed Charges,1859.8,68,,1487.84,Percent of Total Billed Charges,68% of Total Billed Charges,227.98,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,547,20,,437.6,Percent of Total Billed Charges,20% of Total Billed Charges,547,20,,437.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,547,20,,437.6,Percent of Total Billed Charges,20% of Total Billed Charges,547,20,,437.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1777.75,65,,1422.2,Percent of Total Billed Charges,65% of Total Billed Charges,1777.75,65,,1422.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1859.8,
CT ABDOMEN W/WO CONTRAST,5220037,CDM,352,RC,74170,HCPCS,Outpatient,,,2163,1081.50,,1405.95,65,,1124.76,Percent of Total Billed Charges,65% of Total Billed Charges,1470.84,68,,1176.672,Percent of Total Billed Charges,68% of Total Billed Charges,282.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,432.6,20,,346.08,Percent of Total Billed Charges,20% of Total Billed Charges,432.6,20,,346.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.6,20,,346.08,Percent of Total Billed Charges,20% of Total Billed Charges,432.6,20,,346.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1405.95,65,,1124.76,Percent of Total Billed Charges,65% of Total Billed Charges,1405.95,65,,1124.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1470.84,
CT ABDOMEN W/O CONTRAST,5220039,CDM,352,RC,74150,HCPCS,Outpatient,,,978.5,489.25,,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,665.38,68,,532.304,Percent of Total Billed Charges,68% of Total Billed Charges,189,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665.38,
CT KIDNEY W/O CONTRAST,5220041,CDM,352,RC,74150,HCPCS,Outpatient,,,906.4,453.20,,589.16,65,,471.328,Percent of Total Billed Charges,65% of Total Billed Charges,616.35,68,,493.08,Percent of Total Billed Charges,68% of Total Billed Charges,189,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,181.28,20,,145.024,Percent of Total Billed Charges,20% of Total Billed Charges,181.28,20,,145.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.28,20,,145.024,Percent of Total Billed Charges,20% of Total Billed Charges,181.28,20,,145.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.16,65,,471.328,Percent of Total Billed Charges,65% of Total Billed Charges,589.16,65,,471.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,616.35,
CT LIVER W/WO CONTRAST,5220043,CDM,352,RC,74170,HCPCS,Outpatient,,,1038.24,519.12,,674.86,65,,539.888,Percent of Total Billed Charges,65% of Total Billed Charges,706,68,,564.8,Percent of Total Billed Charges,68% of Total Billed Charges,282.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,207.65,20,,166.12,Percent of Total Billed Charges,20% of Total Billed Charges,207.65,20,,166.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.65,20,,166.12,Percent of Total Billed Charges,20% of Total Billed Charges,207.65,20,,166.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,674.86,65,,539.888,Percent of Total Billed Charges,65% of Total Billed Charges,674.86,65,,539.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,706,
CT PELVIS W CONTRAST,5220045,CDM,352,RC,72193,HCPCS,Outpatient,,,1596.5,798.25,,1037.73,65,,830.184,Percent of Total Billed Charges,65% of Total Billed Charges,1085.62,68,,868.496,Percent of Total Billed Charges,68% of Total Billed Charges,227.98,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,319.3,20,,255.44,Percent of Total Billed Charges,20% of Total Billed Charges,319.3,20,,255.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.3,20,,255.44,Percent of Total Billed Charges,20% of Total Billed Charges,319.3,20,,255.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1037.73,65,,830.184,Percent of Total Billed Charges,65% of Total Billed Charges,1037.73,65,,830.184,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1085.62,
CT PELVIS W/WO CONTRAST,5220047,CDM,352,RC,72194,HCPCS,Outpatient,,,1648,824.00,,1071.2,65,,856.96,Percent of Total Billed Charges,65% of Total Billed Charges,1120.64,68,,896.512,Percent of Total Billed Charges,68% of Total Billed Charges,282.46,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,329.6,20,,263.68,Percent of Total Billed Charges,20% of Total Billed Charges,329.6,20,,263.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,329.6,20,,263.68,Percent of Total Billed Charges,20% of Total Billed Charges,329.6,20,,263.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1071.2,65,,856.96,Percent of Total Billed Charges,65% of Total Billed Charges,1071.2,65,,856.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1120.64,
CT PELVIS W/O CONTRAST,5220049,CDM,352,RC,72192,HCPCS,Outpatient,,,1545,772.50,,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,1050.6,68,,840.48,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1050.6,
CT S-SPINE,5220051,CDM,352,RC,72131,HCPCS,Outpatient,,,1611.95,805.98,,1047.77,65,,838.216,Percent of Total Billed Charges,65% of Total Billed Charges,1096.13,68,,876.904,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,322.39,20,,257.912,Percent of Total Billed Charges,20% of Total Billed Charges,322.39,20,,257.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.39,20,,257.912,Percent of Total Billed Charges,20% of Total Billed Charges,322.39,20,,257.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.77,65,,838.216,Percent of Total Billed Charges,65% of Total Billed Charges,1047.77,65,,838.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1096.13,
CT C-SPINE W/O CONTRAST,5220053,CDM,352,RC,72125,HCPCS,Outpatient,,,721,360.50,,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,490.28,68,,392.224,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,490.28,
CT L-SPINE W/O CONTRAST,5220055,CDM,352,RC,72131,HCPCS,Outpatient,,,849.75,424.88,,552.34,65,,441.872,Percent of Total Billed Charges,65% of Total Billed Charges,577.83,68,,462.264,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,169.95,20,,135.96,Percent of Total Billed Charges,20% of Total Billed Charges,169.95,20,,135.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.95,20,,135.96,Percent of Total Billed Charges,20% of Total Billed Charges,169.95,20,,135.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,552.34,65,,441.872,Percent of Total Billed Charges,65% of Total Billed Charges,552.34,65,,441.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,577.83,
CT T-SPINE W/ CONTRAST,5220057,CDM,352,RC,72129,HCPCS,Outpatient,,,1004.25,502.13,,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,682.89,68,,546.312,Percent of Total Billed Charges,68% of Total Billed Charges,235.97,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,200.85,20,,160.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,652.76,65,,522.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,682.89,
CT T-SPINE W/O CONTRAST,5220059,CDM,352,RC,72128,HCPCS,Outpatient,,,978.5,489.25,,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,665.38,68,,532.304,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,195.7,20,,156.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,636.03,65,,508.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665.38,
CT CHEST W/ CONTRAST,5220061,CDM,352,RC,71260,HCPCS,Outpatient,,,1931.25,965.63,,1255.31,65,,1004.248,Percent of Total Billed Charges,65% of Total Billed Charges,1313.25,68,,1050.6,Percent of Total Billed Charges,68% of Total Billed Charges,235.97,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,386.25,20,,309,Percent of Total Billed Charges,20% of Total Billed Charges,386.25,20,,309,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.25,20,,309,Percent of Total Billed Charges,20% of Total Billed Charges,386.25,20,,309,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1255.31,65,,1004.248,Percent of Total Billed Charges,65% of Total Billed Charges,1255.31,65,,1004.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1313.25,
CT CHEST W/WO CONTRAST,5220063,CDM,352,RC,71270,HCPCS,Outpatient,,,3296,1648.00,,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,2241.28,68,,1793.024,Percent of Total Billed Charges,68% of Total Billed Charges,294.28,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,659.2,20,,527.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,2142.4,65,,1713.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2241.28,
CT CHEST W/O CONTRAST,5220065,CDM,352,RC,71250,HCPCS,Outpatient,,,2678,1339.00,,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,1821.04,68,,1456.832,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1821.04,
CT UPPER EXTR W/ CONTRAST LEFT,5220067,CDM,352,RC,73201,HCPCS,Outpatient,,,1108.28,554.14,,720.38,65,,576.304,Percent of Total Billed Charges,65% of Total Billed Charges,753.63,68,,602.904,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,221.66,20,,177.328,Percent of Total Billed Charges,20% of Total Billed Charges,221.66,20,,177.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.66,20,,177.328,Percent of Total Billed Charges,20% of Total Billed Charges,221.66,20,,177.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,720.38,65,,576.304,Percent of Total Billed Charges,65% of Total Billed Charges,720.38,65,,576.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,753.63,
CT UPPER EXTR W/O CONTRAST LEFT,5220069,CDM,352,RC,73200,HCPCS,Outpatient,,,1133,566.50,,736.45,65,,589.16,Percent of Total Billed Charges,65% of Total Billed Charges,770.44,68,,616.352,Percent of Total Billed Charges,68% of Total Billed Charges,165.51,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,226.6,20,,181.28,Percent of Total Billed Charges,20% of Total Billed Charges,226.6,20,,181.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.6,20,,181.28,Percent of Total Billed Charges,20% of Total Billed Charges,226.6,20,,181.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,736.45,65,,589.16,Percent of Total Billed Charges,65% of Total Billed Charges,736.45,65,,589.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,770.44,
CT UPPER EXTR W/WO CONTRAST LEFT,5220071,CDM,352,RC,73202,HCPCS,Outpatient,,,1632.55,816.28,,1061.16,65,,848.928,Percent of Total Billed Charges,65% of Total Billed Charges,1110.13,68,,888.104,Percent of Total Billed Charges,68% of Total Billed Charges,247.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,326.51,20,,261.208,Percent of Total Billed Charges,20% of Total Billed Charges,326.51,20,,261.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.51,20,,261.208,Percent of Total Billed Charges,20% of Total Billed Charges,326.51,20,,261.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1061.16,65,,848.928,Percent of Total Billed Charges,65% of Total Billed Charges,1061.16,65,,848.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1110.13,
CT LOWER EXTR W CONTRAST LEFT,5220073,CDM,352,RC,73701,HCPCS,Outpatient,,,1055.75,527.88,,686.24,65,,548.992,Percent of Total Billed Charges,65% of Total Billed Charges,717.91,68,,574.328,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,211.15,20,,168.92,Percent of Total Billed Charges,20% of Total Billed Charges,211.15,20,,168.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.15,20,,168.92,Percent of Total Billed Charges,20% of Total Billed Charges,211.15,20,,168.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,686.24,65,,548.992,Percent of Total Billed Charges,65% of Total Billed Charges,686.24,65,,548.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,717.91,
CT LOWER EXTR W/O CONTRAST LEFT,5220075,CDM,352,RC,73700,HCPCS,Outpatient,,,1648,824.00,,1071.2,65,,856.96,Percent of Total Billed Charges,65% of Total Billed Charges,1120.64,68,,896.512,Percent of Total Billed Charges,68% of Total Billed Charges,165.51,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,329.6,20,,263.68,Percent of Total Billed Charges,20% of Total Billed Charges,329.6,20,,263.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,329.6,20,,263.68,Percent of Total Billed Charges,20% of Total Billed Charges,329.6,20,,263.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1071.2,65,,856.96,Percent of Total Billed Charges,65% of Total Billed Charges,1071.2,65,,856.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1120.64,
CT LOWER EXTR W/WO LEFT,5220077,CDM,352,RC,73702,HCPCS,Outpatient,,,1192.74,596.37,,775.28,65,,620.224,Percent of Total Billed Charges,65% of Total Billed Charges,811.06,68,,648.848,Percent of Total Billed Charges,68% of Total Billed Charges,247.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,238.55,20,,190.84,Percent of Total Billed Charges,20% of Total Billed Charges,238.55,20,,190.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.55,20,,190.84,Percent of Total Billed Charges,20% of Total Billed Charges,238.55,20,,190.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,775.28,65,,620.224,Percent of Total Billed Charges,65% of Total Billed Charges,775.28,65,,620.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,811.06,
CTA CHEST,5220079,CDM,352,RC,71275,HCPCS,Outpatient,,,1081.5,540.75,,702.98,65,,562.384,Percent of Total Billed Charges,65% of Total Billed Charges,735.42,68,,588.336,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.3,20,,173.04,Percent of Total Billed Charges,20% of Total Billed Charges,216.3,20,,173.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.3,20,,173.04,Percent of Total Billed Charges,20% of Total Billed Charges,216.3,20,,173.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,702.98,65,,562.384,Percent of Total Billed Charges,65% of Total Billed Charges,702.98,65,,562.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,735.42,
CTA LEG BILATERAL,5220081,CDM,352,RC,73706,HCPCS,Outpatient,,,1108.28,554.14,,720.38,65,,576.304,Percent of Total Billed Charges,65% of Total Billed Charges,753.63,68,,602.904,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.66,20,,177.328,Percent of Total Billed Charges,20% of Total Billed Charges,221.66,20,,177.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.66,20,,177.328,Percent of Total Billed Charges,20% of Total Billed Charges,221.66,20,,177.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,720.38,65,,576.304,Percent of Total Billed Charges,65% of Total Billed Charges,720.38,65,,576.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,753.63,
CTA HEAD,5220082,CDM,351,RC,70496,HCPCS,Outpatient,,,3067,1533.50,,1993.55,65,,1594.84,Percent of Total Billed Charges,65% of Total Billed Charges,2085.56,68,,1668.448,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,613.4,20,,490.72,Percent of Total Billed Charges,20% of Total Billed Charges,613.4,20,,490.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,613.4,20,,490.72,Percent of Total Billed Charges,20% of Total Billed Charges,613.4,20,,490.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1993.55,65,,1594.84,Percent of Total Billed Charges,65% of Total Billed Charges,1993.55,65,,1594.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2085.56,
CT L-SPINE W/ CONTRAST,5220083,CDM,352,RC,72132,HCPCS,Outpatient,,,3064,1532.00,,1991.6,65,,1593.28,Percent of Total Billed Charges,65% of Total Billed Charges,2083.52,68,,1666.816,Percent of Total Billed Charges,68% of Total Billed Charges,235.97,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,612.8,20,,490.24,Percent of Total Billed Charges,20% of Total Billed Charges,612.8,20,,490.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.8,20,,490.24,Percent of Total Billed Charges,20% of Total Billed Charges,612.8,20,,490.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1991.6,65,,1593.28,Percent of Total Billed Charges,65% of Total Billed Charges,1991.6,65,,1593.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2083.52,
LOCM 300-399MG/ML IOD1ML,5220085,CDM,636,RC,Q9967,HCPCS,Outpatient,,,200,100.00,,130,65,,104,Percent of Total Billed Charges,65% of Total Billed Charges,136,68,,108.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,20,,32,Percent of Total Billed Charges,20% of Total Billed Charges,40,20,,32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,20,,32,Percent of Total Billed Charges,20% of Total Billed Charges,40,20,,32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160,80,,128,Percent of Total Billed Charges,80% of Total Billed Charges,170,85,,136,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,170,
CT CHEST LOW DOSE,5220086,CDM,352,RC,71271,HCPCS,Outpatient,,,2678,1339.00,,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,1821.04,68,,1456.832,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,535.6,20,,428.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,1740.7,65,,1392.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1821.04,
CT ABDOMEN/PELVIS W/O CONTRAST,5220089,CDM,352,RC,74176,HCPCS,Outpatient,,,2709,1354.50,,1760.85,65,,1408.68,Percent of Total Billed Charges,65% of Total Billed Charges,1842.12,68,,1473.696,Percent of Total Billed Charges,68% of Total Billed Charges,386.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,541.8,20,,433.44,Percent of Total Billed Charges,20% of Total Billed Charges,541.8,20,,433.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,541.8,20,,433.44,Percent of Total Billed Charges,20% of Total Billed Charges,541.8,20,,433.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1760.85,65,,1408.68,Percent of Total Billed Charges,65% of Total Billed Charges,1760.85,65,,1408.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1842.12,
CTA ABDOMEN,5220090,CDM,350,RC,74175,HCPCS,Outpatient,,,2107.38,1053.69,,1369.8,65,,1095.84,Percent of Total Billed Charges,65% of Total Billed Charges,1433.02,68,,1146.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.48,20,,337.184,Percent of Total Billed Charges,20% of Total Billed Charges,421.48,20,,337.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.48,20,,337.184,Percent of Total Billed Charges,20% of Total Billed Charges,421.48,20,,337.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1369.8,65,,1095.84,Percent of Total Billed Charges,65% of Total Billed Charges,1369.8,65,,1095.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1433.02,
CT ABDOMEN/PELVIS W/ CONTRAST,5220091,CDM,352,RC,74177,HCPCS,Outpatient,,,3358,1679.00,,2182.7,65,,1746.16,Percent of Total Billed Charges,65% of Total Billed Charges,2283.44,68,,1826.752,Percent of Total Billed Charges,68% of Total Billed Charges,455.96,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,671.6,20,,537.28,Percent of Total Billed Charges,20% of Total Billed Charges,671.6,20,,537.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.6,20,,537.28,Percent of Total Billed Charges,20% of Total Billed Charges,671.6,20,,537.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2182.7,65,,1746.16,Percent of Total Billed Charges,65% of Total Billed Charges,2182.7,65,,1746.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2283.44,
CTA ABDOMINAL AORTA,5220092,CDM,350,RC,75635,HCPCS,Outpatient,,,3914,1957.00,,2544.1,65,,2035.28,Percent of Total Billed Charges,65% of Total Billed Charges,2661.52,68,,2129.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,782.8,20,,626.24,Percent of Total Billed Charges,20% of Total Billed Charges,782.8,20,,626.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,782.8,20,,626.24,Percent of Total Billed Charges,20% of Total Billed Charges,782.8,20,,626.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2544.1,65,,2035.28,Percent of Total Billed Charges,65% of Total Billed Charges,2544.1,65,,2035.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2661.52,
CT ABD & PELV 1+ SEC/REG,5220093,CDM,352,RC,74178,HCPCS,Outpatient,,,3739,1869.50,,2430.35,65,,1944.28,Percent of Total Billed Charges,65% of Total Billed Charges,2542.52,68,,2034.016,Percent of Total Billed Charges,68% of Total Billed Charges,564.92,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,747.8,20,,598.24,Percent of Total Billed Charges,20% of Total Billed Charges,747.8,20,,598.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.8,20,,598.24,Percent of Total Billed Charges,20% of Total Billed Charges,747.8,20,,598.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2430.35,65,,1944.28,Percent of Total Billed Charges,65% of Total Billed Charges,2430.35,65,,1944.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2542.52,
CT ABDOMEN/PELVIS W/WO CONTRAST,5220094,CDM,352,RC,74178,HCPCS,Outpatient,,,3739,1869.50,,2430.35,65,,1944.28,Percent of Total Billed Charges,65% of Total Billed Charges,2542.52,68,,2034.016,Percent of Total Billed Charges,68% of Total Billed Charges,564.92,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,747.8,20,,598.24,Percent of Total Billed Charges,20% of Total Billed Charges,747.8,20,,598.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.8,20,,598.24,Percent of Total Billed Charges,20% of Total Billed Charges,747.8,20,,598.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2430.35,65,,1944.28,Percent of Total Billed Charges,65% of Total Billed Charges,2430.35,65,,1944.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2542.52,
CTA NECK,5220096,CDM,351,RC,70498,HCPCS,Outpatient,,,2107.38,1053.69,,1369.8,65,,1095.84,Percent of Total Billed Charges,65% of Total Billed Charges,1433.02,68,,1146.416,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.48,20,,337.184,Percent of Total Billed Charges,20% of Total Billed Charges,421.48,20,,337.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.48,20,,337.184,Percent of Total Billed Charges,20% of Total Billed Charges,421.48,20,,337.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1369.8,65,,1095.84,Percent of Total Billed Charges,65% of Total Billed Charges,1369.8,65,,1095.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1433.02,
CT UPPER EXTR W/ CONTRAST RIGHT,5221067,CDM,352,RC,73201,HCPCS,Outpatient,,,1931,965.50,,1255.15,65,,1004.12,Percent of Total Billed Charges,65% of Total Billed Charges,1313.08,68,,1050.464,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,386.2,20,,308.96,Percent of Total Billed Charges,20% of Total Billed Charges,386.2,20,,308.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.2,20,,308.96,Percent of Total Billed Charges,20% of Total Billed Charges,386.2,20,,308.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1255.15,65,,1004.12,Percent of Total Billed Charges,65% of Total Billed Charges,1255.15,65,,1004.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1313.08,
CT UPPER EXTR W/O CONTRAST RIGHT,5221069,CDM,352,RC,73200,HCPCS,Outpatient,,,2343,1171.50,,1522.95,65,,1218.36,Percent of Total Billed Charges,65% of Total Billed Charges,1593.24,68,,1274.592,Percent of Total Billed Charges,68% of Total Billed Charges,165.51,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,468.6,20,,374.88,Percent of Total Billed Charges,20% of Total Billed Charges,468.6,20,,374.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468.6,20,,374.88,Percent of Total Billed Charges,20% of Total Billed Charges,468.6,20,,374.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1522.95,65,,1218.36,Percent of Total Billed Charges,65% of Total Billed Charges,1522.95,65,,1218.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1593.24,
CT UPPER EXTR W/WO CONTRAST RIGHT,5221071,CDM,352,RC,73202,HCPCS,Outpatient,,,3687,1843.50,,2396.55,65,,1917.24,Percent of Total Billed Charges,65% of Total Billed Charges,2507.16,68,,2005.728,Percent of Total Billed Charges,68% of Total Billed Charges,247.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,737.4,20,,589.92,Percent of Total Billed Charges,20% of Total Billed Charges,737.4,20,,589.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,737.4,20,,589.92,Percent of Total Billed Charges,20% of Total Billed Charges,737.4,20,,589.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2396.55,65,,1917.24,Percent of Total Billed Charges,65% of Total Billed Charges,2396.55,65,,1917.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2507.16,
CT LOWER EXTR W CONTRAST RIGHT,5221073,CDM,352,RC,73701,HCPCS,Outpatient,,,1664,832.00,,1081.6,65,,865.28,Percent of Total Billed Charges,65% of Total Billed Charges,1131.52,68,,905.216,Percent of Total Billed Charges,68% of Total Billed Charges,197.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,332.8,20,,266.24,Percent of Total Billed Charges,20% of Total Billed Charges,332.8,20,,266.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.8,20,,266.24,Percent of Total Billed Charges,20% of Total Billed Charges,332.8,20,,266.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1081.6,65,,865.28,Percent of Total Billed Charges,65% of Total Billed Charges,1081.6,65,,865.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1131.52,
CT LOWER EXTR W/O CONTRAST RIGHT,5221075,CDM,352,RC,73700,HCPCS,Outpatient,,,1667,833.50,,1083.55,65,,866.84,Percent of Total Billed Charges,65% of Total Billed Charges,1133.56,68,,906.848,Percent of Total Billed Charges,68% of Total Billed Charges,165.51,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,333.4,20,,266.72,Percent of Total Billed Charges,20% of Total Billed Charges,333.4,20,,266.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.4,20,,266.72,Percent of Total Billed Charges,20% of Total Billed Charges,333.4,20,,266.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1083.55,65,,866.84,Percent of Total Billed Charges,65% of Total Billed Charges,1083.55,65,,866.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1133.56,
CT LOWER EXTR W/WO RIGHT,5221077,CDM,352,RC,73702,HCPCS,Outpatient,,,1947,973.50,,1265.55,65,,1012.44,Percent of Total Billed Charges,65% of Total Billed Charges,1323.96,68,,1059.168,Percent of Total Billed Charges,68% of Total Billed Charges,247.79,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,389.4,20,,311.52,Percent of Total Billed Charges,20% of Total Billed Charges,389.4,20,,311.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.4,20,,311.52,Percent of Total Billed Charges,20% of Total Billed Charges,389.4,20,,311.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1265.55,65,,1012.44,Percent of Total Billed Charges,65% of Total Billed Charges,1265.55,65,,1012.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1323.96,
MA MAMMOGRAM LEFT,5400135,CDM,401,RC,77065,HCPCS,Outpatient,,,310,155.00,,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,210.8,68,,168.64,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,210.8,
MA MAMMOGRAM DIAGNOSTIC BILATERAL,5400136,CDM,401,RC,77066,HCPCS,Outpatient,,,375,187.50,,243.75,65,,195,Percent of Total Billed Charges,65% of Total Billed Charges,255,68,,204,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,20,,60,Percent of Total Billed Charges,20% of Total Billed Charges,75,20,,60,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,20,,60,Percent of Total Billed Charges,20% of Total Billed Charges,75,20,,60,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.75,65,,195,Percent of Total Billed Charges,65% of Total Billed Charges,243.75,65,,195,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,255,
CAD DIAGNOSTIC,5400137,CDM,401,RC,77051,HCPCS,Outpatient,,,123.6,61.80,,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,84.05,68,,67.24,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,91,
MAMO BIL SCRN TO DX,5400138,CDM,401,RC,77067,HCPCS,Outpatient,,,343,171.50,,222.95,65,,178.36,Percent of Total Billed Charges,65% of Total Billed Charges,233.24,68,,186.592,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.95,65,,178.36,Percent of Total Billed Charges,65% of Total Billed Charges,222.95,65,,178.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,233.24,
MA MAMMOGRAM SCRN TO DIAG LEFT,5400139,CDM,401,RC,77065,HCPCS,Outpatient,,,310,155.00,,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,210.8,68,,168.64,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,210.8,
MA MAMMOGRAM SCRN TO DIAG RIGHT,5400140,CDM,401,RC,77065,HCPCS,Outpatient,,,310,155.00,,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,210.8,68,,168.64,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,210.8,
MA MAMMOGRAM SCREENING BILATERAL,5400170,CDM,403,RC,77067,HCPCS,Outpatient,,,343,171.50,,222.95,65,,178.36,Percent of Total Billed Charges,65% of Total Billed Charges,233.24,68,,186.592,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.95,65,,178.36,Percent of Total Billed Charges,65% of Total Billed Charges,222.95,65,,178.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.6,233.24,
MA MAMMOGRAM RIGHT,5400221,CDM,401,RC,77065,HCPCS,Outpatient,,,310,155.00,,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,210.8,68,,168.64,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,62,20,,49.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,201.5,65,,161.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,210.8,
EKG ROUTINE W/ELECT,5580001,CDM,730,RC,93005,HCPCS,Outpatient,,,357.41,178.71,,232.32,65,,185.856,Percent of Total Billed Charges,65% of Total Billed Charges,243.04,68,,194.432,Percent of Total Billed Charges,68% of Total Billed Charges,36.14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,71.48,20,,57.184,Percent of Total Billed Charges,20% of Total Billed Charges,71.48,20,,57.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.48,20,,57.184,Percent of Total Billed Charges,20% of Total Billed Charges,71.48,20,,57.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.32,65,,185.856,Percent of Total Billed Charges,65% of Total Billed Charges,232.32,65,,185.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.14,243.04,
HOLTER MON UP TO 48HR,5580003,CDM,731,RC,93225,HCPCS,Outpatient,,,323.42,161.71,,210.22,65,,168.176,Percent of Total Billed Charges,65% of Total Billed Charges,219.93,68,,175.944,Percent of Total Billed Charges,68% of Total Billed Charges,100.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,64.68,20,,51.744,Percent of Total Billed Charges,20% of Total Billed Charges,64.68,20,,51.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.68,20,,51.744,Percent of Total Billed Charges,20% of Total Billed Charges,64.68,20,,51.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.22,65,,168.176,Percent of Total Billed Charges,65% of Total Billed Charges,210.22,65,,168.176,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,296,
HOLTER MON TO 48/SCAN W/REP,5580004,CDM,731,RC,93226,HCPCS,Outpatient,,,103,51.50,,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,70.04,68,,56.032,Percent of Total Billed Charges,68% of Total Billed Charges,176.5,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,296,
EEG ROUTINE,5590001,CDM,740,RC,95816,HCPCS,Outpatient,,,406.75,203.38,,264.39,65,,211.512,Percent of Total Billed Charges,65% of Total Billed Charges,276.59,68,,221.272,Percent of Total Billed Charges,68% of Total Billed Charges,45.05,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,81.35,20,,65.08,Percent of Total Billed Charges,20% of Total Billed Charges,81.35,20,,65.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.35,20,,65.08,Percent of Total Billed Charges,20% of Total Billed Charges,81.35,20,,65.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.39,65,,211.512,Percent of Total Billed Charges,65% of Total Billed Charges,264.39,65,,211.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.05,665,
ULTRA-COLOR FLO DOPP,5600173,CDM,480,RC,93325,HCPCS,Outpatient,,,254.41,127.21,,165.37,65,,132.296,Percent of Total Billed Charges,65% of Total Billed Charges,173,68,,138.4,Percent of Total Billed Charges,68% of Total Billed Charges,99.69,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,50.88,20,,40.704,Percent of Total Billed Charges,20% of Total Billed Charges,50.88,20,,40.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.88,20,,40.704,Percent of Total Billed Charges,20% of Total Billed Charges,50.88,20,,40.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.37,65,,132.296,Percent of Total Billed Charges,65% of Total Billed Charges,165.37,65,,132.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,591,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.88,591,
ULTRA CARDIAC DOPPLE,5600174,CDM,480,RC,93320,HCPCS,Outpatient,,,355.35,177.68,,230.98,65,,184.784,Percent of Total Billed Charges,65% of Total Billed Charges,241.64,68,,193.312,Percent of Total Billed Charges,68% of Total Billed Charges,58.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,71.07,20,,56.856,Percent of Total Billed Charges,20% of Total Billed Charges,71.07,20,,56.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.07,20,,56.856,Percent of Total Billed Charges,20% of Total Billed Charges,71.07,20,,56.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230.98,65,,184.784,Percent of Total Billed Charges,65% of Total Billed Charges,230.98,65,,184.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,591,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,591,
CT T-SPINE WI PROFEE,5800057,CDM,972,RC,72131,HCPCS,Outpatient,,,285.31,142.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,139.96,110,,,Fee Schedule,110% of Multiplan Fee Schedule,139.96,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,160.96,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,144.69,100,,,Case Rate,Pays Based on per visit rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid rate,92.09,398.86,
CAROTID DUPLEX SCAN UNIL RIGHT PRO FEE,5810224,CDM,972,RC,93882,HCPCS,Outpatient,,,313.64,156.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,131.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,131.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,151.02,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,143.07,100,,,Case Rate,Pays Based on per visit rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid rate,90.47,151.02,
CTA ABDOMINAL AORTA PROFEE,5820092,CDM,972,RC,75635,HCPCS,Outpatient,,,103,51.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,113.3,110,,,Fee Schedule,110% of Multiplan Fee Schedule,113.3,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,130.3,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,254.98,100,,,Case Rate,Pays Based on per visit rate,202.38,100,,,Fee Schedule,100% of FL Medicaid Rate,202.38,100,,,Fee Schedule,100% of FL Medicaid rate,113.3,398.86,
MAMMO/UNILATERAL PRO FEE,5840001,CDM,972,RC,77065,HCPCS,Outpatient,,,176.13,88.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,132.12,110,,,Fee Schedule,110% of Multiplan Fee Schedule,132.12,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,151.94,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,89.18,100,,,Case Rate,Pays Based on Per visit rate,120.05,100,,,Case Rate,Pays Based on per visit rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid rate,67.45,151.94,
AC JOINTS BIL PRO FEE,5840003,CDM,972,RC,73050,HCPCS,Outpatient,,,88.58,44.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.71,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.71,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,35.32,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,72,100,,,Case Rate,Pays Based on per visit rate,19.4,100,,,Fee Schedule,100% of FL Medicaid Rate,19.4,100,,,Fee Schedule,100% of FL Medicaid rate,19.4,176.4,
US ABD DOPPLER+FLOW PRO FEE,5840005,CDM,972,RC,93975,HCPCS,Outpatient,,,237.93,118.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,261.72,110,,,Fee Schedule,110% of Multiplan Fee Schedule,261.72,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,300.98,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,244.59,100,,,Case Rate,Pays Based on per visit rate,191.99,100,,,Fee Schedule,100% of FL Medicaid Rate,191.99,100,,,Fee Schedule,100% of FL Medicaid rate,191.99,300.98,
ABDOMEN 2/VIEWS PRO FEE,5840007,CDM,972,RC,74019,HCPCS,Outpatient,,,74.78,37.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,38.73,110,,,Fee Schedule,110% of Multiplan Fee Schedule,38.73,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,44.54,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,70.99,100,,,Case Rate,Pays Based on per visit rate,18.39,100,,,Fee Schedule,100% of FL Medicaid Rate,18.39,100,,,Fee Schedule,100% of FL Medicaid rate,18.39,176.4,
ANKLE 3 VIEWS BIL PRO FEE,5840009,CDM,972,RC,73610,HCPCS,Outpatient,,,84.98,42.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,38.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,38.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,44.39,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.87,100,,,Case Rate,Pays Based on per visit rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid rate,17.27,176.4,
ANKLE 3 VIEWS LEFT PRO FEE,5840011,CDM,972,RC,73610,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,38.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,38.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,44.39,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.87,100,,,Case Rate,Pays Based on per visit rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid rate,17.27,176.4,
ANKLE 3 VIEWS RIGHT PRO FEE,5840013,CDM,972,RC,73610,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,38.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,38.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,44.39,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.87,100,,,Case Rate,Pays Based on per visit rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid rate,17.27,176.4,
CHEST PORTABLE AP PRO FEE,5840015,CDM,972,RC,71045,HCPCS,Outpatient,,,43.26,21.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,27.27,110,,,Fee Schedule,110% of Multiplan Fee Schedule,27.27,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,31.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,63.66,100,,,Case Rate,Pays Based on per visit rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid rate,11.06,176.4,
BARIUM ENEMA PRO FEE,5840017,CDM,972,RC,74270,HCPCS,Outpatient,,,147.29,73.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,161.73,110,,,Fee Schedule,110% of Multiplan Fee Schedule,161.73,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,185.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,134.7,100,,,Case Rate,Pays Based on per visit rate,82.1,100,,,Fee Schedule,100% of FL Medicaid Rate,82.1,100,,,Fee Schedule,100% of FL Medicaid rate,82.1,185.99,
BE WITH AIR CONTRAST PRO FEE,5840019,CDM,972,RC,74280,HCPCS,Outpatient,,,198.28,99.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,218.11,110,,,Fee Schedule,110% of Multiplan Fee Schedule,218.11,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,250.82,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,169.43,100,,,Case Rate,Pays Based on per visit rate,116.83,100,,,Fee Schedule,100% of FL Medicaid Rate,116.83,100,,,Fee Schedule,100% of FL Medicaid rate,116.83,250.82,
BONE AGE PRO FEE,5840021,CDM,972,RC,77072,HCPCS,Outpatient,,,53.56,26.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,27.63,110,,,Fee Schedule,110% of Multiplan Fee Schedule,27.63,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,31.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,65.22,100,,,Case Rate,Pays Based on per visit rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid rate,12.62,65.22,
CERV SPINE COMPLETE PRO FEE,5840023,CDM,972,RC,72052,HCPCS,Outpatient,,,77.04,38.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,65.92,110,,,Fee Schedule,110% of Multiplan Fee Schedule,65.92,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,75.81,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,83.26,100,,,Case Rate,Pays Based on per visit rate,30.66,100,,,Fee Schedule,100% of FL Medicaid Rate,30.66,100,,,Fee Schedule,100% of FL Medicaid rate,30.66,176.4,
CERV SPINE 2OR3 VIEW PRO FEE,5840025,CDM,972,RC,72040,HCPCS,Outpatient,,,60.05,30.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,41.81,110,,,Fee Schedule,110% of Multiplan Fee Schedule,41.81,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,48.08,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,70.65,100,,,Case Rate,Pays Based on per visit rate,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,18.05,100,,,Fee Schedule,100% of FL Medicaid rate,18.05,176.4,
CHEST PA & LATERAL PRO FEE,5840027,CDM,972,RC,71046,HCPCS,Outpatient,,,53.56,26.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.62,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.62,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,40.96,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.45,100,,,Case Rate,Pays Based on per visit rate,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,16.85,100,,,Fee Schedule,100% of FL Medicaid rate,16.85,176.4,
CHEST PA ONLY PRO FEE,5840029,CDM,972,RC,71045,HCPCS,Outpatient,,,43.26,21.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,27.27,110,,,Fee Schedule,110% of Multiplan Fee Schedule,27.27,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,31.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,63.66,100,,,Case Rate,Pays Based on per visit rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid rate,11.06,176.4,
RIBS BIL MIN 3 V PRO FEE,5840031,CDM,972,RC,71110,HCPCS,Outpatient,,,164.29,82.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,46.44,110,,,Fee Schedule,110% of Multiplan Fee Schedule,46.44,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,53.41,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,73.18,100,,,Case Rate,Pays Based on per visit rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid rate,20.58,176.4,
RIBS 3VW INCL PA CHE PRO FEE,5840033,CDM,972,RC,71101,HCPCS,Outpatient,,,73.65,36.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,44.67,110,,,Fee Schedule,110% of Multiplan Fee Schedule,44.67,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,51.37,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,72.58,100,,,Case Rate,Pays Based on per visit rate,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,19.98,100,,,Fee Schedule,100% of FL Medicaid rate,19.98,176.4,
RIBS PRO FEE,5840035,CDM,972,RC,71101,HCPCS,Outpatient,,,73.65,36.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,44.67,110,,,Fee Schedule,110% of Multiplan Fee Schedule,44.67,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,51.37,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,72.58,100,,,Case Rate,Pays Based on per visit rate,19.98,100,,,Fee Schedule,100% of FL Medicaid Rate,19.98,100,,,Fee Schedule,100% of FL Medicaid rate,19.98,176.4,
CLAVICLE BIL PRO FEE,5840037,CDM,972,RC,73000,HCPCS,Outpatient,,,72.1,36.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.45,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.45,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,39.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.74,100,,,Case Rate,Pays Based on per visit rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid rate,15.14,176.4,
CLAVICLE LEFT PRO FEE,5840039,CDM,972,RC,73000,HCPCS,Outpatient,,,46.45,23.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.45,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.45,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,39.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.74,100,,,Case Rate,Pays Based on per visit rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid rate,15.14,176.4,
CLAVICLE RIGHT PRO FEE,5840041,CDM,972,RC,73000,HCPCS,Outpatient,,,46.45,23.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.45,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.45,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,39.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.74,100,,,Case Rate,Pays Based on per visit rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid rate,15.14,176.4,
COCCYX/SACRUM MIN 2V PRO FEE,5840043,CDM,972,RC,72220,HCPCS,Outpatient,,,57.78,28.89,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.47,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.47,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,39.65,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.93,100,,,Case Rate,Pays Based on per visit rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid rate,15.33,176.4,
DECUBITUS CHEST PRO FEE,5840045,CDM,972,RC,71046,HCPCS,Outpatient,,,47.38,23.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.62,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.62,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,40.96,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.45,100,,,Case Rate,Pays Based on per visit rate,16.85,100,,,Fee Schedule,100% of FL Medicaid Rate,16.85,100,,,Fee Schedule,100% of FL Medicaid rate,16.85,176.4,
ELBOW BIL COMPLETE PRO FEE,5840047,CDM,972,RC,73080,HCPCS,Outpatient,,,149.35,74.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.82,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.82,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,40.04,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.67,100,,,Case Rate,Pays Based on per visit rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid rate,17.07,176.4,
ELBOW COMPLETE LEFT PRO FEE,5840049,CDM,972,RC,73080,HCPCS,Outpatient,,,89.51,44.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.82,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.82,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,40.04,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.67,100,,,Case Rate,Pays Based on per visit rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid rate,17.07,176.4,
CAD DIAGNOSTIC PRO FEE,5840050,CDM,972,RC,77051,HCPCS,Outpatient,,,73.49,36.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
ELBOW 2/VIEWS LTD LEFT PRO FEE,5840051,CDM,972,RC,73070,HCPCS,Outpatient,,,45.32,22.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,31.01,110,,,Fee Schedule,110% of Multiplan Fee Schedule,31.01,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,35.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.55,100,,,Case Rate,Pays Based on per visit rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid rate,14.95,176.4,
ELBOW COMPLETE RIGHT PRO FEE,5840053,CDM,972,RC,73080,HCPCS,Outpatient,,,89.51,44.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.82,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.82,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,40.04,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.67,100,,,Case Rate,Pays Based on per visit rate,17.07,100,,,Fee Schedule,100% of FL Medicaid Rate,17.07,100,,,Fee Schedule,100% of FL Medicaid rate,17.07,176.4,
ELBOW 2/VIEWS LTD RIGHT PRO FEE,5840055,CDM,972,RC,73070,HCPCS,Outpatient,,,45.32,22.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,31.01,110,,,Fee Schedule,110% of Multiplan Fee Schedule,31.01,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,35.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.55,100,,,Case Rate,Pays Based on per visit rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid rate,14.95,176.4,
ESOPHAGUS-BARIUM SW PRO FEE,5840057,CDM,972,RC,74210,HCPCS,Outpatient,,,137.09,68.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,99.79,110,,,Fee Schedule,110% of Multiplan Fee Schedule,99.79,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,114.76,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,93.33,100,,,Case Rate,Pays Based on per visit rate,40.73,100,,,Fee Schedule,100% of FL Medicaid Rate,40.73,100,,,Fee Schedule,100% of FL Medicaid rate,40.73,176.4,
EYE FOREIGN BODY PRO FEE,5840059,CDM,972,RC,70030,HCPCS,Outpatient,,,53.56,26.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.5,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.5,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,39.67,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.74,100,,,Case Rate,Pays Based on per visit rate,15.14,100,,,Fee Schedule,100% of FL Medicaid Rate,15.14,100,,,Fee Schedule,100% of FL Medicaid rate,15.14,176.4,
CAD SCREENING PRO FEE,5840060,CDM,972,RC,77052,HCPCS,Outpatient,,,73.49,36.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
FACIAL BONES MIN 3 V PRO FEE,5840061,CDM,972,RC,70150,HCPCS,Outpatient,,,72.51,36.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,49.82,110,,,Fee Schedule,110% of Multiplan Fee Schedule,49.82,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,57.29,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,75.31,100,,,Case Rate,Pays Based on per visit rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid rate,22.71,176.4,
FEMUR BIL MIN 2 V PRO FEE,5840063,CDM,972,RC,73552,HCPCS,Outpatient,,,89.51,44.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,37.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,37.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,43.24,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,70.46,100,,,Case Rate,Pays Based on per visit rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid rate,17.86,176.4,
FEMUR MIN 2 V LEFT PRO FEE,5840065,CDM,972,RC,73552,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,37.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,37.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,43.24,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,70.46,100,,,Case Rate,Pays Based on per visit rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid rate,17.86,176.4,
FEMUR MIN 2 V RIGHT PRO FEE,5840067,CDM,972,RC,73552,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,37.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,37.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,43.24,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,70.46,100,,,Case Rate,Pays Based on per visit rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid rate,17.86,176.4,
FINGER BIL MIN 2 V PRO FEE,5840069,CDM,972,RC,73140,HCPCS,Outpatient,,,62.32,31.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,40.24,110,,,Fee Schedule,110% of Multiplan Fee Schedule,40.24,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,46.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.87,100,,,Case Rate,Pays Based on per visit rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid rate,17.27,176.4,
FINGER MIN 2 V LEFT PRO FEE,5840071,CDM,972,RC,73140,HCPCS,Outpatient,,,37.39,18.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,40.24,110,,,Fee Schedule,110% of Multiplan Fee Schedule,40.24,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,46.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.87,100,,,Case Rate,Pays Based on per visit rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid rate,17.27,176.4,
FINGER MIN 2 V RIGHT PRO FEE,5840073,CDM,972,RC,73140,HCPCS,Outpatient,,,37.39,18.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,40.24,110,,,Fee Schedule,110% of Multiplan Fee Schedule,40.24,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,46.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.87,100,,,Case Rate,Pays Based on per visit rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid rate,17.27,176.4,
FLUORSCOPY =<1HR PRO FEE,5840075,CDM,972,RC,76000,HCPCS,Outpatient,,,81.37,40.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,45.46,110,,,Fee Schedule,110% of Multiplan Fee Schedule,45.46,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,52.28,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,82.67,100,,,Case Rate,Pays Based on per visit rate,30.07,100,,,Fee Schedule,100% of FL Medicaid Rate,30.07,100,,,Fee Schedule,100% of FL Medicaid rate,30.07,176.4,
FOOT BIL MIN 3 V PRO FEE,5840077,CDM,972,RC,73630,HCPCS,Outpatient,,,89.51,44.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.19,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.19,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,41.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
FOOT MIN 3 V LEFT PRO FEE,5840079,CDM,972,RC,73630,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.19,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.19,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,41.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
FOOT MIN 3 V RIGHT PRO FEE,5840081,CDM,972,RC,73630,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.19,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.19,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,41.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
FOREARM BIL MIN 2 V PRO FEE,5840083,CDM,972,RC,73090,HCPCS,Outpatient,,,75.19,37.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,31.01,110,,,Fee Schedule,110% of Multiplan Fee Schedule,31.01,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,35.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.77,100,,,Case Rate,Pays Based on per visit rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid rate,14.17,176.4,
FOREARM MIN 2 V LEFT PRO FEE,5840085,CDM,972,RC,73090,HCPCS,Outpatient,,,46.45,23.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,31.01,110,,,Fee Schedule,110% of Multiplan Fee Schedule,31.01,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,35.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.77,100,,,Case Rate,Pays Based on per visit rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid rate,14.17,176.4,
FOREARM MIN 2 V RIGHT PRO FEE,5840087,CDM,972,RC,73090,HCPCS,Outpatient,,,46.45,23.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,31.01,110,,,Fee Schedule,110% of Multiplan Fee Schedule,31.01,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,35.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.77,100,,,Case Rate,Pays Based on per visit rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid rate,14.17,176.4,
GI WITH SMALL BOWEL PRO FEE,5840091,CDM,972,RC,74249,HCPCS,Outpatient,,,198.28,99.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.4,100,,,Case Rate,Pays Based on Per visit rate,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,176.4,
HAND BIL MIN 3 V PRO FEE,5840093,CDM,972,RC,73130,HCPCS,Outpatient,,,84.98,42.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,39.29,110,,,Fee Schedule,110% of Multiplan Fee Schedule,39.29,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,45.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.49,100,,,Case Rate,Pays Based on per visit rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid rate,16.89,176.4,
HAND MIN 3 V LEFT PRO FEE,5840095,CDM,972,RC,73130,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,39.29,110,,,Fee Schedule,110% of Multiplan Fee Schedule,39.29,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,45.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.49,100,,,Case Rate,Pays Based on per visit rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid rate,16.89,176.4,
HAND MIN 3 V RIGHT PRO FEE,5840097,CDM,972,RC,73130,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,39.29,110,,,Fee Schedule,110% of Multiplan Fee Schedule,39.29,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,45.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.49,100,,,Case Rate,Pays Based on per visit rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid rate,16.89,176.4,
HEEL BIL MIN 2 V PRO FEE,5840099,CDM,972,RC,73650,HCPCS,Outpatient,,,79.31,39.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,34.86,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.35,100,,,Case Rate,Pays Based on per visit rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid rate,14.75,176.4,
MRI BRAIN W/O CONTRAST PRO FEE,5840100,CDM,972,RC,70551,HCPCS,Outpatient,,,334.75,167.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,213.36,110,,,Fee Schedule,110% of Multiplan Fee Schedule,213.36,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,245.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,724.22,100,,,Case Rate,Pays Based on Per visit rate,218.88,100,,,Case Rate,Pays Based on per visit rate,166.28,100,,,Fee Schedule,100% of FL Medicaid Rate,166.28,100,,,Fee Schedule,100% of FL Medicaid rate,166.28,724.22,
HEEL MIN 2 V LEFT PRO FEE,5840101,CDM,972,RC,73650,HCPCS,Outpatient,,,46.45,23.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,34.86,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.35,100,,,Case Rate,Pays Based on per visit rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid rate,14.75,176.4,
HEEL MIN 2 V RIGHT PRO FEE,5840103,CDM,972,RC,73650,HCPCS,Outpatient,,,46.45,23.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,34.86,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.35,100,,,Case Rate,Pays Based on per visit rate,14.75,100,,,Fee Schedule,100% of FL Medicaid Rate,14.75,100,,,Fee Schedule,100% of FL Medicaid rate,14.75,176.4,
HIP BIL MIN 2 V PRO FEE,5840105,CDM,972,RC,73521,HCPCS,Outpatient,,,132.56,66.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,43.53,110,,,Fee Schedule,110% of Multiplan Fee Schedule,43.53,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,50.06,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,73.29,100,,,Case Rate,Pays Based on per visit rate,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,20.69,100,,,Fee Schedule,100% of FL Medicaid rate,20.69,176.4,
HIP MIN 2 V LEFT PRO FEE,5840107,CDM,972,RC,73502,HCPCS,Outpatient,,,72.51,36.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,50.07,110,,,Fee Schedule,110% of Multiplan Fee Schedule,50.07,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,57.58,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,75.31,100,,,Case Rate,Pays Based on per visit rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid rate,22.71,176.4,
HIP MIN 2 V RIGHT PRO FEE,5840109,CDM,972,RC,73502,HCPCS,Outpatient,,,72.51,36.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,50.07,110,,,Fee Schedule,110% of Multiplan Fee Schedule,50.07,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,57.58,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,75.31,100,,,Case Rate,Pays Based on per visit rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid rate,22.71,176.4,
HUMERUS BIL 2 V PRO FEE,5840111,CDM,972,RC,73060,HCPCS,Outpatient,,,81.37,40.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.76,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.76,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,38.82,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
HUMERUS MIN 2 V LEFT PRO FEE,5840113,CDM,972,RC,73060,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.76,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.76,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,38.82,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
HUMERUS MIN 2 V RIGHT PRO FEE,5840115,CDM,972,RC,73060,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.76,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.76,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,38.82,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
IVP PRO FEE,5840117,CDM,972,RC,74400,HCPCS,Outpatient,,,46.35,23.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,50.99,110,,,Fee Schedule,110% of Multiplan Fee Schedule,50.99,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,58.63,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,112.88,100,,,Case Rate,Pays Based on per visit rate,60.28,100,,,Fee Schedule,100% of FL Medicaid Rate,60.28,100,,,Fee Schedule,100% of FL Medicaid rate,50.99,176.4,
KUB SNGL V PRO FEE,5840119,CDM,972,RC,74018,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,32.09,110,,,Fee Schedule,110% of Multiplan Fee Schedule,32.09,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,36.9,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.72,100,,,Case Rate,Pays Based on per visit rate,15.12,100,,,Fee Schedule,100% of FL Medicaid Rate,15.12,100,,,Fee Schedule,100% of FL Medicaid rate,15.12,176.4,
KIDDOGRAM PRO FEE,5840121,CDM,972,RC,77076,HCPCS,Outpatient,,,64.58,32.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,71.04,110,,,Fee Schedule,110% of Multiplan Fee Schedule,71.04,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,81.69,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,105.5,100,,,Case Rate,Pays Based on per visit rate,52.9,100,,,Fee Schedule,100% of FL Medicaid Rate,52.9,100,,,Fee Schedule,100% of FL Medicaid rate,52.9,105.5,
KNEE BIL MIN 2 V PRO FEE,5840123,CDM,972,RC,73560,HCPCS,Outpatient,,,82.71,41.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.17,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.17,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,41.59,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.49,100,,,Case Rate,Pays Based on per visit rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid rate,16.89,176.4,
KNEE LT MIN 2 V PRO FEE,5840125,CDM,972,RC,73560,HCPCS,Outpatient,,,47.59,23.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.17,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.17,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,41.59,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.49,100,,,Case Rate,Pays Based on per visit rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid rate,16.89,176.4,
KNEE RT MIN 2 V PRO FEE,5840127,CDM,972,RC,73560,HCPCS,Outpatient,,,47.59,23.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.17,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.17,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,41.59,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.49,100,,,Case Rate,Pays Based on per visit rate,16.89,100,,,Fee Schedule,100% of FL Medicaid Rate,16.89,100,,,Fee Schedule,100% of FL Medicaid rate,16.89,176.4,
KNEE BILATERAL 4/VIE PRO FEE,5840129,CDM,972,RC,73564,HCPCS,Outpatient,,,120.1,60.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,49.73,110,,,Fee Schedule,110% of Multiplan Fee Schedule,49.73,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,57.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,74.34,100,,,Case Rate,Pays Based on per visit rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid rate,21.74,176.4,
KNEE 4/VIEW LEFT PRO FEE,5840131,CDM,972,RC,73564,HCPCS,Outpatient,,,65.71,32.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,49.73,110,,,Fee Schedule,110% of Multiplan Fee Schedule,49.73,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,57.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,74.34,100,,,Case Rate,Pays Based on per visit rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid rate,21.74,176.4,
KNEE 4/VIEW RIGHT PRO FEE,5840133,CDM,972,RC,73564,HCPCS,Outpatient,,,65.71,32.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,49.73,110,,,Fee Schedule,110% of Multiplan Fee Schedule,49.73,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,57.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,74.34,100,,,Case Rate,Pays Based on per visit rate,21.74,100,,,Fee Schedule,100% of FL Medicaid Rate,21.74,100,,,Fee Schedule,100% of FL Medicaid rate,21.74,176.4,
LUMBAR SPINE 2 VIEW PRO FEE,5840135,CDM,972,RC,72100,HCPCS,Outpatient,,,64.58,32.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,42.15,110,,,Fee Schedule,110% of Multiplan Fee Schedule,42.15,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,48.47,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,71.82,100,,,Case Rate,Pays Based on per visit rate,19.22,100,,,Fee Schedule,100% of FL Medicaid Rate,19.22,100,,,Fee Schedule,100% of FL Medicaid rate,19.22,176.4,
LUMBAR SP MIN:4 VIEW PRO FEE,5840137,CDM,972,RC,72110,HCPCS,Outpatient,,,84.98,42.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,54.64,110,,,Fee Schedule,110% of Multiplan Fee Schedule,54.64,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,62.83,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,79.38,100,,,Case Rate,Pays Based on per visit rate,26.78,100,,,Fee Schedule,100% of FL Medicaid Rate,26.78,100,,,Fee Schedule,100% of FL Medicaid rate,26.78,176.4,
MAMO/UNILATERAL RIGHT PRO FEE,5840139,CDM,972,RC,77065,HCPCS,Outpatient,,,63.86,31.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.25,110,,,Fee Schedule,110% of Multiplan Fee Schedule,70.25,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,80.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,89.18,100,,,Case Rate,Pays Based on Per visit rate,120.05,100,,,Case Rate,Pays Based on per visit rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid rate,67.45,120.05,
MAMMO DIAG PRO FEE,5840141,CDM,972,RC,77066,HCPCS,Outpatient,,,82.4,41.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,90.64,110,,,Fee Schedule,110% of Multiplan Fee Schedule,90.64,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,104.24,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,89.18,100,,,Case Rate,Pays Based on Per visit rate,138.31,100,,,Case Rate,Pays Based on per visit rate,85.71,100,,,Fee Schedule,100% of FL Medicaid Rate,85.71,100,,,Fee Schedule,100% of FL Medicaid rate,85.71,138.31,
MAMO-BIL SCREENING PRO FEE,5840143,CDM,972,RC,77067,HCPCS,Outpatient,,,70.04,35.02,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,77.04,110,,,Fee Schedule,110% of Multiplan Fee Schedule,77.04,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,88.6,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,89.18,100,,,Case Rate,Pays Based on Per visit rate,122.85,100,,,Case Rate,Pays Based on per visit rate,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,70.25,100,,,Fee Schedule,100% of FL Medicaid rate,70.25,122.85,
MAMO/UNILATERAL LEFT PRO FEE,5840147,CDM,972,RC,77065,HCPCS,Outpatient,,,63.86,31.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.25,110,,,Fee Schedule,110% of Multiplan Fee Schedule,70.25,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,80.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,89.18,100,,,Case Rate,Pays Based on Per visit rate,120.05,100,,,Case Rate,Pays Based on per visit rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid rate,67.45,120.05,
MANDIBLE MIN 4 V PRO FEE,5840149,CDM,972,RC,70110,HCPCS,Outpatient,,,70.25,35.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,46,110,,,Fee Schedule,110% of Multiplan Fee Schedule,46,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,52.9,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,73.37,100,,,Case Rate,Pays Based on per visit rate,20.77,100,,,Fee Schedule,100% of FL Medicaid Rate,20.77,100,,,Fee Schedule,100% of FL Medicaid rate,20.77,176.4,
FLUORO CENTRAL VENOUS ACCESS  PROFEE,5840150,CDM,972,RC,77001,HCPCS,Outpatient,,,73.49,36.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,80.84,110,,,Fee Schedule,110% of Multiplan Fee Schedule,80.84,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,92.96,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,99.01,100,,,Case Rate,Pays Based on per visit rate,46.41,100,,,Fee Schedule,100% of FL Medicaid Rate,46.41,100,,,Fee Schedule,100% of FL Medicaid rate,46.41,99.01,
NASAL BONES MIN 3 V PRO FEE,5840155,CDM,972,RC,70160,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,39.63,110,,,Fee Schedule,110% of Multiplan Fee Schedule,39.63,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,45.58,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,70.46,100,,,Case Rate,Pays Based on per visit rate,17.86,100,,,Fee Schedule,100% of FL Medicaid Rate,17.86,100,,,Fee Schedule,100% of FL Medicaid rate,17.86,176.4,
ORBITS MIN 4 V PRO FEE,5840159,CDM,972,RC,70200,HCPCS,Outpatient,,,66.95,33.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,50.55,110,,,Fee Schedule,110% of Multiplan Fee Schedule,50.55,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,58.13,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,75.7,100,,,Case Rate,Pays Based on per visit rate,23.1,100,,,Fee Schedule,100% of FL Medicaid Rate,23.1,100,,,Fee Schedule,100% of FL Medicaid rate,23.1,176.4,
PELVIS 1-2 V PRO FEE,5840161,CDM,972,RC,72170,HCPCS,Outpatient,,,49.85,24.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,29.66,110,,,Fee Schedule,110% of Multiplan Fee Schedule,29.66,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,34.1,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,70.06,100,,,Case Rate,Pays Based on per visit rate,17.46,100,,,Fee Schedule,100% of FL Medicaid Rate,17.46,100,,,Fee Schedule,100% of FL Medicaid rate,17.46,176.4,
SI JOINT BIL PRO FEE,5840165,CDM,972,RC,72200,HCPCS,Outpatient,,,95.17,47.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.16,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.16,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,40.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.13,100,,,Case Rate,Pays Based on per visit rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid rate,15.53,176.4,
SI JOINT LEFT PRO FEE,5840167,CDM,972,RC,72200,HCPCS,Outpatient,,,48.41,24.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.16,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.16,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,40.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.13,100,,,Case Rate,Pays Based on per visit rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid rate,15.53,176.4,
SI JOINT RIGHT PRO FEE,5840169,CDM,972,RC,72200,HCPCS,Outpatient,,,48.41,24.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.16,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.16,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,40.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.13,100,,,Case Rate,Pays Based on per visit rate,15.53,100,,,Fee Schedule,100% of FL Medicaid Rate,15.53,100,,,Fee Schedule,100% of FL Medicaid rate,15.53,176.4,
ULTRASOUND CHEST PRO FEE,5840170,CDM,972,RC,76604,HCPCS,Outpatient,,,144.2,72.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,60.9,110,,,Fee Schedule,110% of Multiplan Fee Schedule,60.9,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,70.03,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,101.32,100,,,Case Rate,Pays Based on per visit rate,48.72,100,,,Fee Schedule,100% of FL Medicaid Rate,48.72,100,,,Fee Schedule,100% of FL Medicaid rate,48.72,176.4,
SCAPULA BIL PRO FEE,5840171,CDM,972,RC,73010,HCPCS,Outpatient,,,81.37,40.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,25.52,110,,,Fee Schedule,110% of Multiplan Fee Schedule,25.52,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,29.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.09,100,,,Case Rate,Pays Based on per visit rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid rate,16.49,176.4,
SCAPULA LEFT PRO FEE,5840173,CDM,972,RC,73010,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,25.52,110,,,Fee Schedule,110% of Multiplan Fee Schedule,25.52,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,29.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.09,100,,,Case Rate,Pays Based on per visit rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid rate,16.49,176.4,
SCAPULA RIGHT PRO FEE,5840175,CDM,972,RC,73010,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,25.52,110,,,Fee Schedule,110% of Multiplan Fee Schedule,25.52,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,29.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.09,100,,,Case Rate,Pays Based on per visit rate,16.49,100,,,Fee Schedule,100% of FL Medicaid Rate,16.49,100,,,Fee Schedule,100% of FL Medicaid rate,16.49,176.4,
SCR/BAR ENE ALT COID PRO FEE,5840177,CDM,972,RC,G0106,HCPCS,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.78,110,,,Fee Schedule,110% of Multiplan Fee Schedule,57.78,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,66.45,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.78,66.45,
SCR/BAR ENE-ALT SIGM PRO FEE,5840179,CDM,972,RC,G0106,HCPCS,Outpatient,,,52.53,26.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.78,110,,,Fee Schedule,110% of Multiplan Fee Schedule,57.78,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,66.45,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.78,66.45,
SHOULDER BIL 1 VIEW PRO FEE,5840183,CDM,972,RC,73020,HCPCS,Outpatient,,,67.98,33.99,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,23.07,110,,,Fee Schedule,110% of Multiplan Fee Schedule,23.07,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,26.53,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,65.22,100,,,Case Rate,Pays Based on per visit rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid rate,12.62,176.4,
SHOULD BIL MIN:2VIEW PRO FEE,5840185,CDM,972,RC,73030,HCPCS,Outpatient,,,91.77,45.89,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.91,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.91,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,42.44,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
SHOULDER 1 VIEW LEFT PRO FEE,5840187,CDM,972,RC,73020,HCPCS,Outpatient,,,44.19,22.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,23.07,110,,,Fee Schedule,110% of Multiplan Fee Schedule,23.07,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,26.53,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,65.22,100,,,Case Rate,Pays Based on per visit rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid rate,12.62,176.4,
SHOULD MIN: 2 VIEW LEFT PRO FEE,5840189,CDM,972,RC,73030,HCPCS,Outpatient,,,52.12,26.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.91,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.91,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,42.44,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
SHOULDER 1 VIEW RIGHT PRO FEE,5840191,CDM,972,RC,73020,HCPCS,Outpatient,,,40.17,20.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,23.07,110,,,Fee Schedule,110% of Multiplan Fee Schedule,23.07,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,26.53,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,65.22,100,,,Case Rate,Pays Based on per visit rate,12.62,100,,,Fee Schedule,100% of FL Medicaid Rate,12.62,100,,,Fee Schedule,100% of FL Medicaid rate,12.62,176.4,
SHOULD MIN: 2 VIEW RIGHT PRO FEE,5840193,CDM,972,RC,73030,HCPCS,Outpatient,,,52.12,26.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,36.91,110,,,Fee Schedule,110% of Multiplan Fee Schedule,36.91,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,42.44,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
SINUS (WATER) ONLY PRO FEE,5840195,CDM,972,RC,70210,HCPCS,Outpatient,,,52.12,26.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.13,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.13,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,39.25,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.91,100,,,Case Rate,Pays Based on per visit rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid rate,16.31,176.4,
SINUS COM MIN 3 V PRO FEE,5840197,CDM,972,RC,70220,HCPCS,Outpatient,,,75.91,37.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,39.74,110,,,Fee Schedule,110% of Multiplan Fee Schedule,39.74,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,45.7,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,73.18,100,,,Case Rate,Pays Based on per visit rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid rate,20.58,176.4,
SKULL<4 V PRO FEE,5840199,CDM,972,RC,70250,HCPCS,Outpatient,,,58.92,29.46,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,37.94,110,,,Fee Schedule,110% of Multiplan Fee Schedule,37.94,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,43.63,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,72.39,100,,,Case Rate,Pays Based on per visit rate,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,19.79,100,,,Fee Schedule,100% of FL Medicaid rate,19.79,176.4,
SKULL SERIES 4 VIEW PRO FEE,5840201,CDM,972,RC,70260,HCPCS,Outpatient,,,82.71,41.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,47.1,110,,,Fee Schedule,110% of Multiplan Fee Schedule,47.1,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,54.17,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,77.64,100,,,Case Rate,Pays Based on per visit rate,25.04,100,,,Fee Schedule,100% of FL Medicaid Rate,25.04,100,,,Fee Schedule,100% of FL Medicaid rate,25.04,176.4,
SOFT TISSUE NECK PRO FEE,5840203,CDM,972,RC,70360,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.12,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.12,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,38.09,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.93,100,,,Case Rate,Pays Based on per visit rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid rate,15.33,176.4,
STERNUM MIN 2 V PRO FEE,5840205,CDM,972,RC,71120,HCPCS,Outpatient,,,52.12,26.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.57,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.57,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,40.91,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.71,100,,,Case Rate,Pays Based on per visit rate,16.11,100,,,Fee Schedule,100% of FL Medicaid Rate,16.11,100,,,Fee Schedule,100% of FL Medicaid rate,16.11,176.4,
T M JOINTS BIL PRO FEE,5840207,CDM,972,RC,70330,HCPCS,Outpatient,,,71.38,35.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,55.63,110,,,Fee Schedule,110% of Multiplan Fee Schedule,55.63,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,63.97,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,78.5,100,,,Case Rate,Pays Based on per visit rate,25.9,100,,,Fee Schedule,100% of FL Medicaid Rate,25.9,100,,,Fee Schedule,100% of FL Medicaid rate,25.9,176.4,
T-TUBE CHOLONGIOGRAM PRO FEE,5840209,CDM,972,RC,74320,HCPCS,Outpatient,,,109.18,54.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.4,100,,,Case Rate,Pays Based on Per visit rate,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,176.4,
THORACIC SPINE/SWIM PRO FEE,5840211,CDM,972,RC,72072,HCPCS,Outpatient,,,60.05,30.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,41.83,110,,,Fee Schedule,110% of Multiplan Fee Schedule,41.83,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,48.11,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,71.42,100,,,Case Rate,Pays Based on per visit rate,18.82,100,,,Fee Schedule,100% of FL Medicaid Rate,18.82,100,,,Fee Schedule,100% of FL Medicaid rate,18.82,176.4,
TIB/FIB BIL MIN 2 V PRO FEE,5840213,CDM,972,RC,73590,HCPCS,Outpatient,,,82.71,41.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,38.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.32,100,,,Case Rate,Pays Based on per visit rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid rate,15.72,176.4,
TIB/FIB MIN 2 V LEFT PRO FEE,5840215,CDM,972,RC,73590,HCPCS,Outpatient,,,47.59,23.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,38.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.32,100,,,Case Rate,Pays Based on per visit rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid rate,15.72,176.4,
TIB/FIB MIN 2 V RIGHT PRO FEE,5840217,CDM,972,RC,73590,HCPCS,Outpatient,,,47.59,23.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,38.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.32,100,,,Case Rate,Pays Based on per visit rate,15.72,100,,,Fee Schedule,100% of FL Medicaid Rate,15.72,100,,,Fee Schedule,100% of FL Medicaid rate,15.72,176.4,
TOE-L MIN 2 V PRO FEE,5840219,CDM,972,RC,73660,HCPCS,Outpatient,,,38.52,19.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.94,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.94,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,35.58,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.93,100,,,Case Rate,Pays Based on per visit rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid rate,15.33,176.4,
TOE-R MIN 2 V PRO FEE,5840221,CDM,972,RC,73660,HCPCS,Outpatient,,,38.52,19.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.94,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.94,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,35.58,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.93,100,,,Case Rate,Pays Based on per visit rate,15.33,100,,,Fee Schedule,100% of FL Medicaid Rate,15.33,100,,,Fee Schedule,100% of FL Medicaid rate,15.33,176.4,
US INFANT HIPS DYNAMIC PRO FEE,5840222,CDM,972,RC,76886,HCPCS,Outpatient,,,92.7,46.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,101.97,110,,,Fee Schedule,110% of Multiplan Fee Schedule,101.97,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,117.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,103.76,100,,,Case Rate,Pays Based on per visit rate,51.16,100,,,Fee Schedule,100% of FL Medicaid Rate,51.16,100,,,Fee Schedule,100% of FL Medicaid rate,51.16,117.27,
US SOFT TISSUE HEAD & NECK PRO FEE,5840223,CDM,972,RC,76536,HCPCS,Outpatient,,,144.2,72.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,115.9,110,,,Fee Schedule,110% of Multiplan Fee Schedule,115.9,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,133.28,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,116.85,100,,,Case Rate,Pays Based on per visit rate,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,64.25,100,,,Fee Schedule,100% of FL Medicaid rate,64.25,176.4,
CAROTID DUPLEX SCAN UNIL LEFT PRO FEE,5840224,CDM,972,RC,93882,HCPCS,Outpatient,,,313.64,156.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,131.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,131.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,151.02,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,143.07,100,,,Case Rate,Pays Based on per visit rate,90.47,100,,,Fee Schedule,100% of FL Medicaid Rate,90.47,100,,,Fee Schedule,100% of FL Medicaid rate,90.47,151.02,
ULTRA AORTA PRO FEE,5840225,CDM,972,RC,76706,HCPCS,Outpatient,,,174.48,87.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,112.09,110,,,Fee Schedule,110% of Multiplan Fee Schedule,112.09,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,128.9,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,107.76,100,,,Case Rate,Pays Based on per visit rate,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,55.16,100,,,Fee Schedule,100% of FL Medicaid rate,55.16,176.4,
ULTRA NON VAS EXT PRO FEE,5840227,CDM,972,RC,76881,HCPCS,Outpatient,,,144.2,72.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,58.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,58.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,67.07,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,108.83,100,,,Case Rate,Pays Based on per visit rate,56.23,100,,,Fee Schedule,100% of FL Medicaid Rate,56.23,100,,,Fee Schedule,100% of FL Medicaid rate,56.23,176.4,
ULTRA DOPPER AORTA PRO FEE,5840229,CDM,972,RC,93978,HCPCS,Outpatient,,,123.6,61.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,135.96,110,,,Fee Schedule,110% of Multiplan Fee Schedule,135.96,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,156.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,176.2,100,,,Case Rate,Pays Based on per visit rate,123.6,100,,,Fee Schedule,100% of FL Medicaid Rate,123.6,100,,,Fee Schedule,100% of FL Medicaid rate,123.6,176.2,
ULTRA ABDOMINAL COMP PRO FEE,5840231,CDM,972,RC,76700,HCPCS,Outpatient,,,210.74,105.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,123.02,110,,,Fee Schedule,110% of Multiplan Fee Schedule,123.02,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,141.48,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,120.14,100,,,Case Rate,Pays Based on per visit rate,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,67.54,100,,,Fee Schedule,100% of FL Medicaid rate,67.54,176.4,
ULTRA CAROTID BILAT PRO FEE,5840233,CDM,972,RC,93880,HCPCS,Outpatient,,,214.14,107.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,199.82,110,,,Fee Schedule,110% of Multiplan Fee Schedule,199.82,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,229.79,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,190.82,100,,,Case Rate,Pays Based on per visit rate,138.22,100,,,Fee Schedule,100% of FL Medicaid Rate,138.22,100,,,Fee Schedule,100% of FL Medicaid rate,138.22,229.79,
ULTRA PREG UTER LTD PRO FEE,5840235,CDM,972,RC,76815,HCPCS,Outpatient,,,120.1,60.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,85.81,110,,,Fee Schedule,110% of Multiplan Fee Schedule,85.81,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,98.68,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,99.57,100,,,Case Rate,Pays Based on per visit rate,46.97,100,,,Fee Schedule,100% of FL Medicaid Rate,46.97,100,,,Fee Schedule,100% of FL Medicaid rate,46.97,176.4,
ULTRA GALL BLADDER PRO FEE,5840237,CDM,972,RC,76705,HCPCS,Outpatient,,,143.89,71.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,91.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,91.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,105.65,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,103.06,100,,,Case Rate,Pays Based on per visit rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid rate,50.46,176.4,
ULTRA PELVIC NON OB PRO FEE,5840239,CDM,972,RC,76856,HCPCS,Outpatient,,,150.69,75.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,111.02,110,,,Fee Schedule,110% of Multiplan Fee Schedule,111.02,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,127.68,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,113.54,100,,,Case Rate,Pays Based on per visit rate,60.94,100,,,Fee Schedule,100% of FL Medicaid Rate,60.94,100,,,Fee Schedule,100% of FL Medicaid rate,60.94,176.4,
US PG UTER>14WKS SN PRO FEE,5840241,CDM,972,RC,76805,HCPCS,Outpatient,,,186.95,93.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,143.37,110,,,Fee Schedule,110% of Multiplan Fee Schedule,143.37,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,164.88,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,131.39,100,,,Case Rate,Pays Based on per visit rate,78.79,100,,,Fee Schedule,100% of FL Medicaid Rate,78.79,100,,,Fee Schedule,100% of FL Medicaid rate,78.79,176.4,
ULTRA SCROTUM PRO FEE,5840243,CDM,972,RC,76870,HCPCS,Outpatient,,,156.35,78.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,105.4,110,,,Fee Schedule,110% of Multiplan Fee Schedule,105.4,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,121.21,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,95.24,100,,,Case Rate,Pays Based on per visit rate,42.64,100,,,Fee Schedule,100% of FL Medicaid Rate,42.64,100,,,Fee Schedule,100% of FL Medicaid rate,42.64,121.21,
US ABD LIMITED PRO FEE,5840245,CDM,972,RC,76705,HCPCS,Outpatient,,,143.89,71.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,91.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,91.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,105.65,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,103.06,100,,,Case Rate,Pays Based on per visit rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid rate,50.46,176.4,
US ST HEAD AND NECK PRO FEE,5840247,CDM,972,RC,76536,HCPCS,Outpatient,,,157.49,78.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,115.9,110,,,Fee Schedule,110% of Multiplan Fee Schedule,115.9,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,133.28,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,116.85,100,,,Case Rate,Pays Based on per visit rate,64.25,100,,,Fee Schedule,100% of FL Medicaid Rate,64.25,100,,,Fee Schedule,100% of FL Medicaid rate,64.25,176.4,
ULTRA TRNVAG NON PG PRO FEE,5840251,CDM,972,RC,76830,HCPCS,Outpatient,,,164.29,82.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,125.66,110,,,Fee Schedule,110% of Multiplan Fee Schedule,125.66,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,144.51,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,120.14,100,,,Case Rate,Pays Based on per visit rate,67.54,100,,,Fee Schedule,100% of FL Medicaid Rate,67.54,100,,,Fee Schedule,100% of FL Medicaid rate,67.54,176.4,
ULTRA BREAST BIL PRO FEE,5840253,CDM,972,RC,76641,HCPCS,Outpatient,,,316.11,158.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,108.55,110,,,Fee Schedule,110% of Multiplan Fee Schedule,108.55,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,124.83,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,110.76,100,,,Case Rate,Pays Based on per visit rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid rate,58.16,176.4,
ULTRA BREAST LEFT PRO FEE,5840255,CDM,972,RC,76641,HCPCS,Outpatient,,,164.29,82.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,108.55,110,,,Fee Schedule,110% of Multiplan Fee Schedule,108.55,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,124.83,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,110.76,100,,,Case Rate,Pays Based on per visit rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid rate,58.16,176.4,
ULTRA BREAST RIGHT PRO FEE,5840257,CDM,972,RC,76641,HCPCS,Outpatient,,,164.29,82.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,108.55,110,,,Fee Schedule,110% of Multiplan Fee Schedule,108.55,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,124.83,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,110.76,100,,,Case Rate,Pays Based on per visit rate,58.16,100,,,Fee Schedule,100% of FL Medicaid Rate,58.16,100,,,Fee Schedule,100% of FL Medicaid rate,58.16,176.4,
ULTRA RENAL BIL PRO FEE,5840259,CDM,972,RC,76770,HCPCS,Outpatient,,,336.5,168.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,114.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,114.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,131.59,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,115.09,100,,,Case Rate,Pays Based on per visit rate,62.49,100,,,Fee Schedule,100% of FL Medicaid Rate,62.49,100,,,Fee Schedule,100% of FL Medicaid rate,62.49,176.4,
ULTRA RENAL LEFT PRO FEE,5840261,CDM,972,RC,76775,HCPCS,Outpatient,,,158.62,79.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,63.62,110,,,Fee Schedule,110% of Multiplan Fee Schedule,63.62,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,73.17,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,89.88,100,,,Case Rate,Pays Based on per visit rate,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,37.28,100,,,Fee Schedule,100% of FL Medicaid rate,37.28,176.4,
ULTRA RENAL RIGHT PRO FEE,5840263,CDM,972,RC,76775,HCPCS,Outpatient,,,158.62,79.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,63.62,110,,,Fee Schedule,110% of Multiplan Fee Schedule,63.62,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,73.17,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,89.88,100,,,Case Rate,Pays Based on per visit rate,37.28,100,,,Fee Schedule,100% of FL Medicaid Rate,37.28,100,,,Fee Schedule,100% of FL Medicaid rate,37.28,176.4,
ULT/UPP EXTR ART BIL PRO FEE,5840265,CDM,972,RC,93930,HCPCS,Outpatient,,,183.55,91.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,201.91,110,,,Fee Schedule,110% of Multiplan Fee Schedule,201.91,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,232.19,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,194.43,100,,,Case Rate,Pays Based on per visit rate,141.83,100,,,Fee Schedule,100% of FL Medicaid Rate,141.83,100,,,Fee Schedule,100% of FL Medicaid rate,141.83,232.19,
ULT/UPP EXTR ART LEFT PRO FEE,5840267,CDM,972,RC,93931,HCPCS,Outpatient,,,87.55,43.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,96.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,96.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,110.75,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,140.15,100,,,Case Rate,Pays Based on per visit rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid rate,87.55,140.15,
ULT/UPP EXTR ART RIGHT PRO FEE,5840269,CDM,972,RC,93931,HCPCS,Outpatient,,,87.55,43.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,96.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,96.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,110.75,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,140.15,100,,,Case Rate,Pays Based on per visit rate,87.55,100,,,Fee Schedule,100% of FL Medicaid Rate,87.55,100,,,Fee Schedule,100% of FL Medicaid rate,87.55,140.15,
ULT/LOW EXTR ART BIL PRO FEE,5840271,CDM,972,RC,93925,HCPCS,Outpatient,,,203.94,101.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,224.33,110,,,Fee Schedule,110% of Multiplan Fee Schedule,224.33,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,257.98,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,227.55,100,,,Case Rate,Pays Based on per visit rate,174.95,100,,,Fee Schedule,100% of FL Medicaid Rate,174.95,100,,,Fee Schedule,100% of FL Medicaid rate,174.95,257.98,
ULT/LOW EXTR ART LEFT PRO FEE,5840273,CDM,972,RC,93926,HCPCS,Outpatient,,,118.97,59.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,130.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,130.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,150.5,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,156.03,100,,,Case Rate,Pays Based on per visit rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid rate,103.43,156.03,
ULT/LOW EXTR ART RIGHT PRO FEE,5840275,CDM,972,RC,93926,HCPCS,Outpatient,,,118.97,59.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,130.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,130.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,150.5,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,156.03,100,,,Case Rate,Pays Based on per visit rate,103.43,100,,,Fee Schedule,100% of FL Medicaid Rate,103.43,100,,,Fee Schedule,100% of FL Medicaid rate,103.43,156.03,
ULTRA VENUS BIL PRO FEE,5840277,CDM,972,RC,93970,HCPCS,Outpatient,,,363.69,181.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,196.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,196.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,225.75,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,188.43,100,,,Case Rate,Pays Based on per visit rate,135.83,100,,,Fee Schedule,100% of FL Medicaid Rate,135.83,100,,,Fee Schedule,100% of FL Medicaid rate,135.83,225.75,
ULTRA VENOUS L EXTREM PRO FEE,5840279,CDM,972,RC,93971,HCPCS,Outpatient,,,112.17,56.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,123.39,110,,,Fee Schedule,110% of Multiplan Fee Schedule,123.39,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,141.9,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,138.24,100,,,Case Rate,Pays Based on per visit rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid rate,85.64,141.9,
ULTRA VENUS EXTREM PRO FEE,5840281,CDM,972,RC,93971,HCPCS,Outpatient,,,112.17,56.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,123.39,110,,,Fee Schedule,110% of Multiplan Fee Schedule,123.39,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,141.9,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,138.24,100,,,Case Rate,Pays Based on per visit rate,85.64,100,,,Fee Schedule,100% of FL Medicaid Rate,85.64,100,,,Fee Schedule,100% of FL Medicaid rate,85.64,141.9,
UPPER GI SERIES PRO FEE,5840283,CDM,972,RC,74246,HCPCS,Outpatient,,,141.63,70.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,146.62,110,,,Fee Schedule,110% of Multiplan Fee Schedule,146.62,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,168.61,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,122.07,100,,,Case Rate,Pays Based on per visit rate,69.47,100,,,Fee Schedule,100% of FL Medicaid Rate,69.47,100,,,Fee Schedule,100% of FL Medicaid rate,69.47,176.4,
US RUQ PRO FEE,5840285,CDM,972,RC,76705,HCPCS,Outpatient,,,89.51,44.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,91.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,91.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,105.65,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,103.06,100,,,Case Rate,Pays Based on per visit rate,50.46,100,,,Fee Schedule,100% of FL Medicaid Rate,50.46,100,,,Fee Schedule,100% of FL Medicaid rate,50.46,176.4,
VOID CYSTOURETHOGRAM PRO FEE,5840287,CDM,972,RC,74455,HCPCS,Outpatient,,,69.01,34.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,75.91,110,,,Fee Schedule,110% of Multiplan Fee Schedule,75.91,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,87.3,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,97.43,100,,,Case Rate,Pays Based on per visit rate,44.83,100,,,Fee Schedule,100% of FL Medicaid Rate,44.83,100,,,Fee Schedule,100% of FL Medicaid rate,44.83,176.4,
WRIST BIL 2 VIEWS PRO FEE,5840289,CDM,972,RC,73100,HCPCS,Outpatient,,,66.85,33.43,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.83,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.83,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,41.2,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
WRIST BIL MIN: 3 VIEW PRO FEE,5840291,CDM,972,RC,73110,HCPCS,Outpatient,,,84.98,42.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,43.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,43.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,49.93,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,71.95,100,,,Case Rate,Pays Based on per visit rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid rate,19.35,176.4,
WRIST 2 VIEWS LEFT PRO FEE,5840293,CDM,972,RC,73100,HCPCS,Outpatient,,,46.45,23.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.83,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.83,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,41.2,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
WRIST MIN 3 V LEFT PRO FEE,5840295,CDM,972,RC,73110,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,43.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,43.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,49.93,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,71.95,100,,,Case Rate,Pays Based on per visit rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid rate,19.35,176.4,
WRIST 2 VIEWS RIGHT PRO FEE,5840297,CDM,972,RC,73100,HCPCS,Outpatient,,,46.45,23.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.83,110,,,Fee Schedule,110% of Multiplan Fee Schedule,35.83,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,41.2,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.51,100,,,Case Rate,Pays Based on per visit rate,15.91,100,,,Fee Schedule,100% of FL Medicaid Rate,15.91,100,,,Fee Schedule,100% of FL Medicaid rate,15.91,176.4,
WRIST MIN: 3 VIEW RIGHT PRO FEE,5840299,CDM,972,RC,73110,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,43.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,43.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,49.93,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,71.95,100,,,Case Rate,Pays Based on per visit rate,19.35,100,,,Fee Schedule,100% of FL Medicaid Rate,19.35,100,,,Fee Schedule,100% of FL Medicaid rate,19.35,176.4,
ZYGOMATIC ARCH MIN3V PRO FEE,5840301,CDM,972,RC,70150,HCPCS,Outpatient,,,65.92,32.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,49.82,110,,,Fee Schedule,110% of Multiplan Fee Schedule,49.82,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,57.29,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,75.31,100,,,Case Rate,Pays Based on per visit rate,22.71,100,,,Fee Schedule,100% of FL Medicaid Rate,22.71,100,,,Fee Schedule,100% of FL Medicaid rate,22.71,176.4,
ABDOMINAL SERIES PRO FEE,5840303,CDM,972,RC,74022,HCPCS,Outpatient,,,91.77,45.89,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,52.89,110,,,Fee Schedule,110% of Multiplan Fee Schedule,52.89,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,60.82,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,77.05,100,,,Case Rate,Pays Based on per visit rate,24.45,100,,,Fee Schedule,100% of FL Medicaid Rate,24.45,100,,,Fee Schedule,100% of FL Medicaid rate,24.45,176.4,
CTHEAD/ BRAIN WI PRO FEE,5840305,CDM,972,RC,70460,HCPCS,Outpatient,,,292.52,146.26,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,160.74,110,,,Fee Schedule,110% of Multiplan Fee Schedule,160.74,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,184.85,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,142.72,100,,,Case Rate,Pays Based on per visit rate,90.12,100,,,Fee Schedule,100% of FL Medicaid Rate,90.12,100,,,Fee Schedule,100% of FL Medicaid rate,90.12,398.86,
CTA ABDOMEN-PROFEE,5840306,CDM,972,RC,74175,HCPCS,Outpatient,,,597.4,298.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,330.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,330.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,379.85,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,221.67,100,,,Case Rate,Pays Based on per visit rate,169.07,100,,,Fee Schedule,100% of FL Medicaid Rate,169.07,100,,,Fee Schedule,100% of FL Medicaid rate,169.07,398.86,
CT HEAD/BRAIN WI/WO PRO FEE,5840307,CDM,972,RC,70470,HCPCS,Outpatient,,,320.33,160.17,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,188.27,110,,,Fee Schedule,110% of Multiplan Fee Schedule,188.27,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,216.5,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,158.12,100,,,Case Rate,Pays Based on per visit rate,105.52,100,,,Fee Schedule,100% of FL Medicaid Rate,105.52,100,,,Fee Schedule,100% of FL Medicaid rate,105.52,398.86,
CTA HEAD-PROFEE,5840308,CDM,972,RC,70496,HCPCS,Outpatient,,,597.4,298.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,298.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,298.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,343.06,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,248.05,100,,,Case Rate,Pays Based on per visit rate,195.45,100,,,Fee Schedule,100% of FL Medicaid Rate,195.45,100,,,Fee Schedule,100% of FL Medicaid rate,195.45,398.86,
CT HEAD/ BRAIN WO PRO FEE,5840309,CDM,972,RC,70450,HCPCS,Outpatient,,,232.78,116.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,115.01,110,,,Fee Schedule,110% of Multiplan Fee Schedule,115.01,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,132.26,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,116.61,100,,,Case Rate,Pays Based on per visit rate,64.01,100,,,Fee Schedule,100% of FL Medicaid Rate,64.01,100,,,Fee Schedule,100% of FL Medicaid rate,64.01,398.86,
CTA ABDOMINAL AORTA-PROFEE,5840310,CDM,972,RC,74150,HCPCS,Outpatient,,,597.4,298.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,148.48,110,,,Fee Schedule,110% of Multiplan Fee Schedule,148.48,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,170.75,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,135.39,100,,,Case Rate,Pays Based on per visit rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid rate,82.79,398.86,
CT FACIAL WO CONTRAS PRO FEE,5840311,CDM,972,RC,70486,HCPCS,Outpatient,,,246.17,123.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,138.41,110,,,Fee Schedule,110% of Multiplan Fee Schedule,138.41,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,159.17,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,135.34,100,,,Case Rate,Pays Based on per visit rate,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,82.74,100,,,Fee Schedule,100% of FL Medicaid rate,82.74,398.86,
CT NECK W CONTRAST PRO FEE,5840315,CDM,972,RC,70491,HCPCS,Outpatient,,,325.48,162.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,199.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,199.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,229.85,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,164.62,100,,,Case Rate,Pays Based on per visit rate,112.02,100,,,Fee Schedule,100% of FL Medicaid Rate,112.02,100,,,Fee Schedule,100% of FL Medicaid rate,112.02,398.86,
ULTRA ECHOCARDIOGRAM-PROFEE,5840316,CDM,972,RC,93307,HCPCS,Outpatient,,,597.4,298.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,143.73,110,,,Fee Schedule,110% of Multiplan Fee Schedule,143.73,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,165.28,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,151.93,100,,,Case Rate,Pays Based on per visit rate,99.33,100,,,Fee Schedule,100% of FL Medicaid Rate,99.33,100,,,Fee Schedule,100% of FL Medicaid rate,99.33,165.28,
CT NECK WI/WO CONTRA PRO FEE,5840317,CDM,972,RC,70492,HCPCS,Outpatient,,,348.14,174.07,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,239.48,110,,,Fee Schedule,110% of Multiplan Fee Schedule,239.48,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,275.4,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,187.5,100,,,Case Rate,Pays Based on per visit rate,134.9,100,,,Fee Schedule,100% of FL Medicaid Rate,134.9,100,,,Fee Schedule,100% of FL Medicaid rate,134.9,398.86,
CT NECK WO CONTRAST PRO FEE,5840319,CDM,972,RC,70490,HCPCS,Outpatient,,,296.64,148.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,162.98,110,,,Fee Schedule,110% of Multiplan Fee Schedule,162.98,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,187.42,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,145.4,100,,,Case Rate,Pays Based on per visit rate,92.8,100,,,Fee Schedule,100% of FL Medicaid Rate,92.8,100,,,Fee Schedule,100% of FL Medicaid rate,92.8,398.86,
CT ORBITS IAC WI PRO FEE,5840321,CDM,972,RC,70481,HCPCS,Outpatient,,,324.45,162.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151,100,,,Fee Schedule,100% of FL Medicaid Rate,151,100,,,Fee Schedule,100% of FL Medicaid Rate,151,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,195.35,110,,,Fee Schedule,110% of Multiplan Fee Schedule,195.35,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,151,100,,,Fee Schedule,100% of FL Medicaid Rate,224.65,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,151,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,151,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,203.6,100,,,Case Rate,Pays Based on per visit rate,151,100,,,Fee Schedule,100% of FL Medicaid Rate,151,100,,,Fee Schedule,100% of FL Medicaid rate,151,398.86,
CT ORBITS IAM WO PRO FEE,5840323,CDM,972,RC,70480,HCPCS,Outpatient,,,296.64,148.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,172.8,110,,,Fee Schedule,110% of Multiplan Fee Schedule,172.8,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,198.72,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,157.09,100,,,Case Rate,Pays Based on per visit rate,104.49,100,,,Fee Schedule,100% of FL Medicaid Rate,104.49,100,,,Fee Schedule,100% of FL Medicaid rate,104.49,398.86,
CT SINUS WI CONTRAST PRO FEE,5840325,CDM,972,RC,70487,HCPCS,Outpatient,,,301.79,150.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,165.06,110,,,Fee Schedule,110% of Multiplan Fee Schedule,165.06,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,189.81,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,153.15,100,,,Case Rate,Pays Based on per visit rate,100.55,100,,,Fee Schedule,100% of FL Medicaid Rate,100.55,100,,,Fee Schedule,100% of FL Medicaid rate,100.55,398.86,
CT SINUS WO CONTRAST PRO FEE,5840327,CDM,972,RC,70486,HCPCS,Outpatient,,,246.17,123.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,138.41,110,,,Fee Schedule,110% of Multiplan Fee Schedule,138.41,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,159.17,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,135.34,100,,,Case Rate,Pays Based on per visit rate,82.74,100,,,Fee Schedule,100% of FL Medicaid Rate,82.74,100,,,Fee Schedule,100% of FL Medicaid rate,82.74,398.86,
CT ABD WI PRO FEE,5840329,CDM,972,RC,74160,HCPCS,Outpatient,,,331.66,165.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,251.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,251.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,289.34,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,179.5,100,,,Case Rate,Pays Based on per visit rate,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,126.9,100,,,Fee Schedule,100% of FL Medicaid rate,126.9,398.86,
CT ABD WI/WO PRO FEE,5840331,CDM,972,RC,74170,HCPCS,Outpatient,,,401.08,200.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,282.51,110,,,Fee Schedule,110% of Multiplan Fee Schedule,282.51,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,324.89,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,196.98,100,,,Case Rate,Pays Based on per visit rate,144.38,100,,,Fee Schedule,100% of FL Medicaid Rate,144.38,100,,,Fee Schedule,100% of FL Medicaid rate,144.38,398.86,
CT ABD WO PRO FEE,5840333,CDM,972,RC,74150,HCPCS,Outpatient,,,309.31,154.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,148.48,110,,,Fee Schedule,110% of Multiplan Fee Schedule,148.48,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,170.75,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,135.39,100,,,Case Rate,Pays Based on per visit rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid rate,82.79,398.86,
CT ABD PELV W/WO CONTRAST PRO FEE,5840334,CDM,972,RC,74178,HCPCS,Outpatient,,,733.05,366.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,367.55,110,,,Fee Schedule,110% of Multiplan Fee Schedule,367.55,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,422.69,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,244.55,100,,,Case Rate,Pays Based on per visit rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid rate,191.95,422.69,
CT KIDNEY WO CONTRAS PRO FEE,5840335,CDM,972,RC,74150,HCPCS,Outpatient,,,309.31,154.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,148.48,110,,,Fee Schedule,110% of Multiplan Fee Schedule,148.48,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,170.75,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,135.39,100,,,Case Rate,Pays Based on per visit rate,82.79,100,,,Fee Schedule,100% of FL Medicaid Rate,82.79,100,,,Fee Schedule,100% of FL Medicaid rate,82.79,398.86,
CT LIVER W/WO CONTRAST PRO FEE,5840337,CDM,972,RC,74160,HCPCS,Outpatient,,,331.66,165.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,251.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,251.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,289.34,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,179.5,100,,,Case Rate,Pays Based on per visit rate,126.9,100,,,Fee Schedule,100% of FL Medicaid Rate,126.9,100,,,Fee Schedule,100% of FL Medicaid rate,126.9,398.86,
CT PELVIS WI PRO FEE,5840339,CDM,972,RC,72193,HCPCS,Outpatient,,,283.25,141.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,246.7,110,,,Fee Schedule,110% of Multiplan Fee Schedule,246.7,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,283.7,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,176.42,100,,,Case Rate,Pays Based on per visit rate,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,123.82,100,,,Fee Schedule,100% of FL Medicaid rate,123.82,398.86,
CT PELVIS WI/WO PRO FEE,5840341,CDM,972,RC,72194,HCPCS,Outpatient,,,301.79,150.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,271.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,271.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,312.75,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,195.5,100,,,Case Rate,Pays Based on per visit rate,142.9,100,,,Fee Schedule,100% of FL Medicaid Rate,142.9,100,,,Fee Schedule,100% of FL Medicaid rate,142.9,398.86,
CT PELVIS WO PRO FEE,5840343,CDM,972,RC,72192,HCPCS,Outpatient,,,262.65,131.33,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,144.47,110,,,Fee Schedule,110% of Multiplan Fee Schedule,144.47,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,166.15,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,133.13,100,,,Case Rate,Pays Based on per visit rate,80.53,100,,,Fee Schedule,100% of FL Medicaid Rate,80.53,100,,,Fee Schedule,100% of FL Medicaid rate,80.53,398.86,
CT SACRUM WO PRO FEE,5840345,CDM,972,RC,72131,HCPCS,Outpatient,,,285.31,142.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,139.96,110,,,Fee Schedule,110% of Multiplan Fee Schedule,139.96,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,160.96,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,144.69,100,,,Case Rate,Pays Based on per visit rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid rate,92.09,398.86,
CT SPINE CERVICAL WO PRO FEE,5840347,CDM,972,RC,72125,HCPCS,Outpatient,,,284.28,142.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,140.99,110,,,Fee Schedule,110% of Multiplan Fee Schedule,140.99,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,162.14,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,146.43,100,,,Case Rate,Pays Based on per visit rate,93.83,100,,,Fee Schedule,100% of FL Medicaid Rate,93.83,100,,,Fee Schedule,100% of FL Medicaid rate,93.83,398.86,
CT SPINE LUMBAR WO PRO FEE,5840349,CDM,972,RC,72131,HCPCS,Outpatient,,,285.31,142.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,139.96,110,,,Fee Schedule,110% of Multiplan Fee Schedule,139.96,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,160.96,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,144.69,100,,,Case Rate,Pays Based on per visit rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid rate,92.09,398.86,
CT T-SPINE WO PRO FEE,5840351,CDM,972,RC,72128,HCPCS,Outpatient,,,206,103.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,140.65,110,,,Fee Schedule,110% of Multiplan Fee Schedule,140.65,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,161.74,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,144.69,100,,,Case Rate,Pays Based on per visit rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid rate,92.09,398.86,
CT SP THORACIC WO PRO FEE,5840353,CDM,972,RC,72128,HCPCS,Outpatient,,,312.09,156.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,140.65,110,,,Fee Schedule,110% of Multiplan Fee Schedule,140.65,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,161.74,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,144.69,100,,,Case Rate,Pays Based on per visit rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid rate,92.09,398.86,
CT CHEST WI PRO FEE,5840355,CDM,972,RC,71260,HCPCS,Outpatient,,,343.3,171.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,180.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,180.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,208.09,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,160.82,100,,,Case Rate,Pays Based on per visit rate,108.22,100,,,Fee Schedule,100% of FL Medicaid Rate,108.22,100,,,Fee Schedule,100% of FL Medicaid rate,108.22,398.86,
CT CHEST WI/WO PRO FEE,5840357,CDM,972,RC,71270,HCPCS,Outpatient,,,380.69,190.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,212.14,110,,,Fee Schedule,110% of Multiplan Fee Schedule,212.14,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,243.96,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,182.15,100,,,Case Rate,Pays Based on per visit rate,129.55,100,,,Fee Schedule,100% of FL Medicaid Rate,129.55,100,,,Fee Schedule,100% of FL Medicaid rate,129.55,398.86,
CT CHEST WO PRO FEE,5840359,CDM,972,RC,71250,HCPCS,Outpatient,,,314.97,157.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,144.45,110,,,Fee Schedule,110% of Multiplan Fee Schedule,144.45,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,166.12,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,142.51,100,,,Case Rate,Pays Based on per visit rate,89.91,100,,,Fee Schedule,100% of FL Medicaid Rate,89.91,100,,,Fee Schedule,100% of FL Medicaid rate,89.91,398.86,
ANKLE BIL 2 VIEW PRO FEE,5840361,CDM,972,RC,73600,HCPCS,Outpatient,,,57.78,28.89,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.11,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.11,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,39.23,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.91,100,,,Case Rate,Pays Based on per visit rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid rate,16.31,176.4,
ANKLE 2 VIEW RIGHT PRO FEE,5840363,CDM,972,RC,73600,HCPCS,Outpatient,,,45.32,22.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.11,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.11,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,39.23,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.91,100,,,Case Rate,Pays Based on per visit rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid rate,16.31,176.4,
ANKLE 2 VIEW LEFT PRO FEE,5840365,CDM,972,RC,73600,HCPCS,Outpatient,,,45.32,22.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.11,110,,,Fee Schedule,110% of Multiplan Fee Schedule,34.11,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,39.23,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,68.91,100,,,Case Rate,Pays Based on per visit rate,16.31,100,,,Fee Schedule,100% of FL Medicaid Rate,16.31,100,,,Fee Schedule,100% of FL Medicaid rate,16.31,176.4,
U/S PREG TRANS VAG PRO FEE,5840367,CDM,972,RC,76817,HCPCS,Outpatient,,,163.15,81.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,98.08,110,,,Fee Schedule,110% of Multiplan Fee Schedule,98.08,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,112.79,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,106.56,100,,,Case Rate,Pays Based on per visit rate,53.96,100,,,Fee Schedule,100% of FL Medicaid Rate,53.96,100,,,Fee Schedule,100% of FL Medicaid rate,53.96,176.4,
CT UPPER EXT WI PRO FEE,5840369,CDM,972,RC,73201,HCPCS,Outpatient,,,206,103.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,216.76,110,,,Fee Schedule,110% of Multiplan Fee Schedule,216.76,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,249.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,174.49,100,,,Case Rate,Pays Based on per visit rate,121.89,100,,,Fee Schedule,100% of FL Medicaid Rate,121.89,100,,,Fee Schedule,100% of FL Medicaid rate,121.89,398.86,
CT UPPER EXT WO PRO FEE,5840371,CDM,972,RC,73200,HCPCS,Outpatient,,,164.8,82.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,174.03,110,,,Fee Schedule,110% of Multiplan Fee Schedule,174.03,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,200.14,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,144.69,100,,,Case Rate,Pays Based on per visit rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid rate,92.09,398.86,
CT UPPER EXT WI/WO PRO FEE,5840373,CDM,972,RC,73202,HCPCS,Outpatient,,,157.59,78.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,173.35,110,,,Fee Schedule,110% of Multiplan Fee Schedule,173.35,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,199.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,205.13,100,,,Case Rate,Pays Based on per visit rate,152.53,100,,,Fee Schedule,100% of FL Medicaid Rate,152.53,100,,,Fee Schedule,100% of FL Medicaid rate,152.53,398.86,
CT LOWER EXT WI PRO FEE,5840375,CDM,972,RC,73701,HCPCS,Outpatient,,,206,103.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,180.61,110,,,Fee Schedule,110% of Multiplan Fee Schedule,180.61,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,207.7,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,176.42,100,,,Case Rate,Pays Based on per visit rate,123.82,100,,,Fee Schedule,100% of FL Medicaid Rate,123.82,100,,,Fee Schedule,100% of FL Medicaid rate,123.82,398.86,
CT LOWER EXT WO PRO FEE,5840377,CDM,972,RC,73700,HCPCS,Outpatient,,,164.8,82.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,140.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,140.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,161.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,144.69,100,,,Case Rate,Pays Based on per visit rate,92.09,100,,,Fee Schedule,100% of FL Medicaid Rate,92.09,100,,,Fee Schedule,100% of FL Medicaid rate,92.09,398.86,
CT LOWER EXT WI/WO PRO FEE,5840379,CDM,972,RC,73702,HCPCS,Outpatient,,,157.59,78.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,173.35,110,,,Fee Schedule,110% of Multiplan Fee Schedule,173.35,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,199.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,203.11,100,,,Case Rate,Pays Based on per visit rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid rate,150.51,398.86,
CT LOWER EXT WI/WO RT PRO FEE,5840380,CDM,972,RC,73702,HCPCS,Outpatient,,,157.59,78.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,173.35,110,,,Fee Schedule,110% of Multiplan Fee Schedule,173.35,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,199.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,203.11,100,,,Case Rate,Pays Based on per visit rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid rate,150.51,398.86,
CTA LUNG PE PRO FEE,5840381,CDM,972,RC,71275,HCPCS,Outpatient,,,482.66,241.33,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,304.49,110,,,Fee Schedule,110% of Multiplan Fee Schedule,304.49,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,350.16,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,217.82,100,,,Case Rate,Pays Based on per visit rate,165.22,100,,,Fee Schedule,100% of FL Medicaid Rate,165.22,100,,,Fee Schedule,100% of FL Medicaid rate,165.22,398.86,
CT LOWER EXT WI/WO LT PRO FEE,5840382,CDM,972,RC,73702,HCPCS,Outpatient,,,157.59,78.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,173.35,110,,,Fee Schedule,110% of Multiplan Fee Schedule,173.35,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,199.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,203.11,100,,,Case Rate,Pays Based on per visit rate,150.51,100,,,Fee Schedule,100% of FL Medicaid Rate,150.51,100,,,Fee Schedule,100% of FL Medicaid rate,150.51,398.86,
CT LIMITED PRO FEE,5840383,CDM,972,RC,76380,HCPCS,Outpatient,,,216.3,108.15,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,141.82,110,,,Fee Schedule,110% of Multiplan Fee Schedule,141.82,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,163.1,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,118.76,100,,,Case Rate,Pays Based on per visit rate,66.16,100,,,Fee Schedule,100% of FL Medicaid Rate,66.16,100,,,Fee Schedule,100% of FL Medicaid rate,66.16,398.86,
CT FACIAL WI/WO PRO FEE,5840385,CDM,972,RC,70488,HCPCS,Outpatient,,,218.36,109.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,199.63,110,,,Fee Schedule,110% of Multiplan Fee Schedule,199.63,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,229.57,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,175.23,100,,,Case Rate,Pays Based on per visit rate,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,122.63,100,,,Fee Schedule,100% of FL Medicaid rate,122.63,229.57,
CT SINUS WI/WO PRO FEE,5840387,CDM,972,RC,70488,HCPCS,Outpatient,,,218.36,109.18,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,199.63,110,,,Fee Schedule,110% of Multiplan Fee Schedule,199.63,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,229.57,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,175.23,100,,,Case Rate,Pays Based on per visit rate,122.63,100,,,Fee Schedule,100% of FL Medicaid Rate,122.63,100,,,Fee Schedule,100% of FL Medicaid rate,122.63,229.57,
APICAL LORDOTIC CHEST PRO FEE,5840389,CDM,972,RC,71045,HCPCS,Outpatient,,,75.19,37.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,27.27,110,,,Fee Schedule,110% of Multiplan Fee Schedule,27.27,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,31.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,63.66,100,,,Case Rate,Pays Based on per visit rate,11.06,100,,,Fee Schedule,100% of FL Medicaid Rate,11.06,100,,,Fee Schedule,100% of FL Medicaid rate,11.06,176.4,
US NEONATAL HEAD PRO FEE,5840391,CDM,972,RC,76506,HCPCS,Outpatient,,,60.77,30.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,66.85,110,,,Fee Schedule,110% of Multiplan Fee Schedule,66.85,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,76.87,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,117.77,100,,,Case Rate,Pays Based on per visit rate,65.17,100,,,Fee Schedule,100% of FL Medicaid Rate,65.17,100,,,Fee Schedule,100% of FL Medicaid rate,65.17,176.4,
FISTULAGRAM INJ PRO FEE,5840393,CDM,972,RC,76080,HCPCS,Outpatient,,,103,51.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,63.72,110,,,Fee Schedule,110% of Multiplan Fee Schedule,63.72,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,73.28,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,82.88,100,,,Case Rate,Pays Based on per visit rate,30.28,100,,,Fee Schedule,100% of FL Medicaid Rate,30.28,100,,,Fee Schedule,100% of FL Medicaid rate,30.28,176.4,
US GUIDE/ASP/BX PRO FEE,5840397,CDM,972,RC,76942,HCPCS,Outpatient,,,133.9,66.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,62.11,110,,,Fee Schedule,110% of Multiplan Fee Schedule,62.11,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,71.42,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,122.7,100,,,Case Rate,Pays Based on per visit rate,70.1,100,,,Fee Schedule,100% of FL Medicaid Rate,70.1,100,,,Fee Schedule,100% of FL Medicaid rate,62.11,176.4,
CYSTOGRAM INJ PRO FEE,5840399,CDM,972,RC,51600,HCPCS,Outpatient,,,312.09,156.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,47.66,110,,,Fee Schedule,110% of Multiplan Fee Schedule,47.66,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,54.81,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.14,100,,,Case Rate,Pays Based on per visit rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid rate,29.54,82.14,
ELBOW BIL 2 VIEW PRO FEE,5840401,CDM,972,RC,73070,HCPCS,Outpatient,,,89.51,44.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,31.01,110,,,Fee Schedule,110% of Multiplan Fee Schedule,31.01,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,35.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.55,100,,,Case Rate,Pays Based on per visit rate,14.95,100,,,Fee Schedule,100% of FL Medicaid Rate,14.95,100,,,Fee Schedule,100% of FL Medicaid rate,14.95,176.4,
FOOT BIL 2 VIEWS PRO FEE,5840403,CDM,972,RC,73620,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,34.86,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.77,100,,,Case Rate,Pays Based on per visit rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid rate,14.17,176.4,
FOOT 2 VIEW LEFT PRO FEE,5840405,CDM,972,RC,73620,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,34.86,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.77,100,,,Case Rate,Pays Based on per visit rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid rate,14.17,176.4,
FOOT 2 VIEW RIGHT PRO FEE,5840407,CDM,972,RC,73620,HCPCS,Outpatient,,,50.99,25.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,30.32,110,,,Fee Schedule,110% of Multiplan Fee Schedule,30.32,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,34.86,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.77,100,,,Case Rate,Pays Based on per visit rate,14.17,100,,,Fee Schedule,100% of FL Medicaid Rate,14.17,100,,,Fee Schedule,100% of FL Medicaid rate,14.17,176.4,
HAND BIL 2 VIEW PRO FEE,5840409,CDM,972,RC,73120,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,38.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.96,100,,,Case Rate,Pays Based on per visit rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid rate,14.36,176.4,
HAND MIN 2 VIEW LEFT PRO FEE,5840411,CDM,972,RC,73120,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,38.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.96,100,,,Case Rate,Pays Based on per visit rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid rate,14.36,176.4,
HAND MIN 2 VIEW RIGHT PRO FEE,5840413,CDM,972,RC,73120,HCPCS,Outpatient,,,48.72,24.36,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,38.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,66.96,100,,,Case Rate,Pays Based on per visit rate,14.36,100,,,Fee Schedule,100% of FL Medicaid Rate,14.36,100,,,Fee Schedule,100% of FL Medicaid rate,14.36,176.4,
MAMO BIL SCRN TO DX PRO FEE,5840415,CDM,972,RC,77067,HCPCS,Outpatient,,,70.04,35.02,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,77.04,110,,,Fee Schedule,110% of Multiplan Fee Schedule,77.04,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,88.6,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,89.18,100,,,Case Rate,Pays Based on Per visit rate,122.85,100,,,Case Rate,Pays Based on per visit rate,70.25,100,,,Fee Schedule,100% of FL Medicaid Rate,70.25,100,,,Fee Schedule,100% of FL Medicaid rate,70.25,122.85,
MAMO UNI SCN TO DX LEFT PRO FEE,5840417,CDM,972,RC,77065,HCPCS,Outpatient,,,63.86,31.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.25,110,,,Fee Schedule,110% of Multiplan Fee Schedule,70.25,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,80.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,89.18,100,,,Case Rate,Pays Based on Per visit rate,120.05,100,,,Case Rate,Pays Based on per visit rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid rate,67.45,120.05,
MAMO UNI SCN TO DX RIGHT PRO FEE,5840419,CDM,972,RC,77065,HCPCS,Outpatient,,,63.86,31.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.25,110,,,Fee Schedule,110% of Multiplan Fee Schedule,70.25,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,80.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,89.18,100,,,Case Rate,Pays Based on Per visit rate,120.05,100,,,Case Rate,Pays Based on per visit rate,67.45,100,,,Fee Schedule,100% of FL Medicaid Rate,67.45,100,,,Fee Schedule,100% of FL Medicaid rate,67.45,120.05,
G TUBE PATENCY CK PRO FEE,5840421,CDM,972,RC,49465,HCPCS,Outpatient,,,93.73,46.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,33.11,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.11,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,38.08,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,72.9,100,,,Case Rate,Pays Based on per visit rate,20.3,100,,,Fee Schedule,100% of FL Medicaid Rate,20.3,100,,,Fee Schedule,100% of FL Medicaid rate,20.3,72.9,
CYSTOGRAM INJ PRO FEE,5840423,CDM,972,RC,51600,HCPCS,Outpatient,,,113.3,56.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,47.66,110,,,Fee Schedule,110% of Multiplan Fee Schedule,47.66,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,54.81,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.14,100,,,Case Rate,Pays Based on per visit rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid rate,29.54,82.14,
FISTULAGRAM INJ PRO FEE,5840425,CDM,972,RC,20501,HCPCS,Outpatient,,,113.3,56.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,39.8,110,,,Fee Schedule,110% of Multiplan Fee Schedule,39.8,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,45.77,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,77.75,100,,,Case Rate,Pays Based on per visit rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid rate,25.15,77.75,
T TUBE CHOL INJ PRO FEE,5840427,CDM,972,RC,47531,HCPCS,Outpatient,,,113.3,56.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,76.19,110,,,Fee Schedule,110% of Multiplan Fee Schedule,76.19,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,87.61,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,99.44,100,,,Case Rate,Pays Based on per visit rate,46.84,100,,,Fee Schedule,100% of FL Medicaid Rate,46.84,100,,,Fee Schedule,100% of FL Medicaid rate,46.84,99.44,
US PG DETAIL EA ADDL PRO FEE,5840429,CDM,972,RC,76812,HCPCS,Outpatient,,,169.95,84.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,186.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,186.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,214.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,166.52,100,,,Case Rate,Pays Based on per visit rate,113.92,100,,,Fee Schedule,100% of FL Medicaid Rate,113.92,100,,,Fee Schedule,100% of FL Medicaid rate,113.92,214.99,
US PG DETAIL SNG PRO FEE,5840431,CDM,972,RC,76811,HCPCS,Outpatient,,,169.95,84.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,186.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,186.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,214.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,154.3,100,,,Case Rate,Pays Based on per visit rate,101.7,100,,,Fee Schedule,100% of FL Medicaid Rate,101.7,100,,,Fee Schedule,100% of FL Medicaid rate,101.7,214.99,
US PG UTER<14WK EA ADD PRO FEE,5840433,CDM,972,RC,76802,HCPCS,Outpatient,,,169.95,84.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,64.34,110,,,Fee Schedule,110% of Multiplan Fee Schedule,64.34,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,73.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,88.32,100,,,Case Rate,Pays Based on per visit rate,35.72,100,,,Fee Schedule,100% of FL Medicaid Rate,35.72,100,,,Fee Schedule,100% of FL Medicaid rate,35.72,176.4,
US PG UTER<14 WK SNG PRO FEE,5840435,CDM,972,RC,76801,HCPCS,Outpatient,,,186.95,93.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,124.26,110,,,Fee Schedule,110% of Multiplan Fee Schedule,124.26,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,142.89,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,120.92,100,,,Case Rate,Pays Based on per visit rate,68.32,100,,,Fee Schedule,100% of FL Medicaid Rate,68.32,100,,,Fee Schedule,100% of FL Medicaid rate,68.32,176.4,
US PG UTR>14WK EA ADD PRO FEE,5840437,CDM,972,RC,76810,HCPCS,Outpatient,,,169.95,84.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,92.88,110,,,Fee Schedule,110% of Multiplan Fee Schedule,92.88,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,106.82,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,104.23,100,,,Case Rate,Pays Based on per visit rate,51.63,100,,,Fee Schedule,100% of FL Medicaid Rate,51.63,100,,,Fee Schedule,100% of FL Medicaid rate,51.63,176.4,
VOID CYSTO INJ PRO FEE,5840439,CDM,972,RC,51600,HCPCS,Outpatient,,,113.3,56.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,47.66,110,,,Fee Schedule,110% of Multiplan Fee Schedule,47.66,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,54.81,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.14,100,,,Case Rate,Pays Based on per visit rate,29.54,100,,,Fee Schedule,100% of FL Medicaid Rate,29.54,100,,,Fee Schedule,100% of FL Medicaid rate,29.54,82.14,
CTA LWR EXT BIL PRO FEE,5840441,CDM,972,RC,73706,HCPCS,Outpatient,,,226.6,113.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,100,,,Fee Schedule,100% of FL Medicaid Rate,189,100,,,Fee Schedule,100% of FL Medicaid Rate,189,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,249.26,110,,,Fee Schedule,110% of Multiplan Fee Schedule,249.26,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,189,100,,,Fee Schedule,100% of FL Medicaid Rate,286.65,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,189,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,189,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,241.6,100,,,Case Rate,Pays Based on per visit rate,189,100,,,Fee Schedule,100% of FL Medicaid Rate,189,100,,,Fee Schedule,100% of FL Medicaid rate,189,398.86,
CT LUMBAR SPINE W PRO FEE,5840443,CDM,972,RC,72132,HCPCS,Outpatient,,,285.31,142.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,183.15,110,,,Fee Schedule,110% of Multiplan Fee Schedule,183.15,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,210.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,177.97,100,,,Case Rate,Pays Based on per visit rate,125.37,100,,,Fee Schedule,100% of FL Medicaid Rate,125.37,100,,,Fee Schedule,100% of FL Medicaid rate,125.37,398.86,
NG TUBE PLACEMENT PRO FEE,5840447,CDM,972,RC,43752,HCPCS,Outpatient,,,44.02,22.01,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,44.26,110,,,Fee Schedule,110% of Multiplan Fee Schedule,44.26,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,50.9,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,80.92,100,,,Case Rate,Pays Based on per visit rate,28.32,100,,,Fee Schedule,100% of FL Medicaid Rate,28.32,100,,,Fee Schedule,100% of FL Medicaid rate,28.32,80.92,
X-RAY RIBS 3 VIEWS BILAT PRO FEE,5840449,CDM,972,RC,71110,HCPCS,Outpatient,,,48.41,24.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,46.44,110,,,Fee Schedule,110% of Multiplan Fee Schedule,46.44,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,53.41,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,73.18,100,,,Case Rate,Pays Based on per visit rate,20.58,100,,,Fee Schedule,100% of FL Medicaid Rate,20.58,100,,,Fee Schedule,100% of FL Medicaid rate,20.58,176.4,
ENTIRE SPINE AP & LAT PRO FEE,5840451,CDM,972,RC,72082,HCPCS,Outpatient,,,79.31,39.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,73.87,110,,,Fee Schedule,110% of Multiplan Fee Schedule,73.87,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,84.94,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,86.75,100,,,Case Rate,Pays Based on per visit rate,34.15,100,,,Fee Schedule,100% of FL Medicaid Rate,34.15,100,,,Fee Schedule,100% of FL Medicaid rate,34.15,176.4,
X-RAY NECK SPINE 4+ VIEW PRO FEE,5840453,CDM,972,RC,72050,HCPCS,Outpatient,,,79.31,39.66,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,56.38,110,,,Fee Schedule,110% of Multiplan Fee Schedule,56.38,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,64.83,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,77.44,100,,,Case Rate,Pays Based on per visit rate,24.84,100,,,Fee Schedule,100% of FL Medicaid Rate,24.84,100,,,Fee Schedule,100% of FL Medicaid rate,24.84,176.4,
X-RAY SI JOINTS 3+ VIEWS PRO FEE,5840455,CDM,972,RC,72202,HCPCS,Outpatient,,,48.41,24.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,41.49,110,,,Fee Schedule,110% of Multiplan Fee Schedule,41.49,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,47.72,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,70.65,100,,,Case Rate,Pays Based on per visit rate,18.05,100,,,Fee Schedule,100% of FL Medicaid Rate,18.05,100,,,Fee Schedule,100% of FL Medicaid rate,18.05,176.4,
COLN SCN BE ALT TO CNSPY PRO FEE,5840457,CDM,972,RC,G0120,HCPCS,Outpatient,,,89.61,44.81,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.57,110,,,Fee Schedule,110% of Multiplan Fee Schedule,98.57,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,113.36,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.57,113.36,
BE COLORECTAL CA SCRN PRO FEE,5840459,CDM,972,RC,G0122,HCPCS,Outpatient,,,103,51.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.3,110,,,Fee Schedule,110% of Multiplan Fee Schedule,113.3,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,130.3,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.3,130.3,
US EXAM AAA SCREEN PRO FEE,5840461,CDM,972,RC,76706,HCPCS,Outpatient,,,99.91,49.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,109.9,110,,,Fee Schedule,110% of Multiplan Fee Schedule,109.9,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,126.39,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,107.76,100,,,Case Rate,Pays Based on per visit rate,55.16,100,,,Fee Schedule,100% of FL Medicaid Rate,55.16,100,,,Fee Schedule,100% of FL Medicaid rate,55.16,176.4,
UGI W AIR W KUB PRO FEE,5840463,CDM,972,RC,74247,HCPCS,Outpatient,,,128.75,64.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.4,100,,,Case Rate,Pays Based on Per visit rate,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,176.4,
UGI W KUB PRO FEE,5840465,CDM,972,RC,74240,HCPCS,Outpatient,,,128.75,64.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,129.35,110,,,Fee Schedule,110% of Multiplan Fee Schedule,129.35,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,148.75,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,114.31,100,,,Case Rate,Pays Based on per visit rate,61.71,100,,,Fee Schedule,100% of FL Medicaid Rate,61.71,100,,,Fee Schedule,100% of FL Medicaid rate,61.71,176.4,
UGI W SM BOWEL PRO FEE,5840467,CDM,972,RC,74245,HCPCS,Outpatient,,,147.29,73.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.4,100,,,Case Rate,Pays Based on Per visit rate,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,176.4,
ESOPHOGRAM PRO FEE,5840469,CDM,972,RC,74220,HCPCS,Outpatient,,,90.64,45.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,99.7,110,,,Fee Schedule,110% of Multiplan Fee Schedule,99.7,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,114.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,100.94,100,,,Case Rate,Pays Based on per visit rate,48.34,100,,,Fee Schedule,100% of FL Medicaid Rate,48.34,100,,,Fee Schedule,100% of FL Medicaid rate,48.34,176.4,
CON X-RAY BLADDER 3+VIEW PRO FEE,5840471,CDM,972,RC,74430,HCPCS,Outpatient,,,16.48,8.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,18.13,110,,,Fee Schedule,110% of Multiplan Fee Schedule,18.13,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,20.85,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,76.31,100,,,Case Rate,Pays Based on per visit rate,23.71,100,,,Fee Schedule,100% of FL Medicaid Rate,23.71,100,,,Fee Schedule,100% of FL Medicaid rate,18.13,176.4,
CT ABD & PELV WI CON PRO FEE,5840473,CDM,972,RC,74177,HCPCS,Outpatient,,,676.4,338.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,327.53,110,,,Fee Schedule,110% of Multiplan Fee Schedule,327.53,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,376.65,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,223.2,100,,,Case Rate,Pays Based on per visit rate,170.6,100,,,Fee Schedule,100% of FL Medicaid Rate,170.6,100,,,Fee Schedule,100% of FL Medicaid rate,170.6,398.86,
CT ABD & PELV 1+SEC/REG PRO FEE,5840475,CDM,972,RC,74178,HCPCS,Outpatient,,,733.05,366.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,367.55,110,,,Fee Schedule,110% of Multiplan Fee Schedule,367.55,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,422.69,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,244.55,100,,,Case Rate,Pays Based on per visit rate,191.95,100,,,Fee Schedule,100% of FL Medicaid Rate,191.95,100,,,Fee Schedule,100% of FL Medicaid rate,191.95,422.69,
CT ABD &PELV W/O CON PRO FEE,5840477,CDM,972,RC,74176,HCPCS,Outpatient,,,598.22,299.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,199.66,110,,,Fee Schedule,110% of Multiplan Fee Schedule,199.66,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,229.61,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,162.84,100,,,Case Rate,Pays Based on per visit rate,110.24,100,,,Fee Schedule,100% of FL Medicaid Rate,110.24,100,,,Fee Schedule,100% of FL Medicaid rate,110.24,398.86,
US XTR NON-VASC LMTD PRO FEE,5840479,CDM,972,RC,76882,HCPCS,Outpatient,,,65.92,32.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.85,110,,,Fee Schedule,110% of Multiplan Fee Schedule,67.85,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,78.03,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,72.39,100,,,Case Rate,Pays Based on per visit rate,19.79,100,,,Fee Schedule,100% of FL Medicaid Rate,19.79,100,,,Fee Schedule,100% of FL Medicaid rate,19.79,176.4,
X-RAY PEL & HIPS 2+VIEW PRO FEE,5840481,CDM,972,RC,73521,HCPCS,Outpatient,,,48.41,24.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,43.53,110,,,Fee Schedule,110% of Multiplan Fee Schedule,43.53,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,50.06,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,73.29,100,,,Case Rate,Pays Based on per visit rate,20.69,100,,,Fee Schedule,100% of FL Medicaid Rate,20.69,100,,,Fee Schedule,100% of FL Medicaid rate,20.69,176.4,
X-RAY LEG INFANT 2 VIEW PRO FEE,5840483,CDM,972,RC,73592,HCPCS,Outpatient,,,48.41,24.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33.42,110,,,Fee Schedule,110% of Multiplan Fee Schedule,33.42,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,38.43,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,67.14,100,,,Case Rate,Pays Based on per visit rate,14.54,100,,,Fee Schedule,100% of FL Medicaid Rate,14.54,100,,,Fee Schedule,100% of FL Medicaid rate,14.54,176.4,
CTA NECK PRO FEE,5840485,CDM,972,RC,70498,HCPCS,Outpatient,,,597.4,298.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,297.96,110,,,Fee Schedule,110% of Multiplan Fee Schedule,297.96,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,342.65,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,398.86,100,,,Case Rate,Pays Based on Per visit rate,249.07,100,,,Case Rate,Pays Based on per visit rate,196.47,100,,,Fee Schedule,100% of FL Medicaid Rate,196.47,100,,,Fee Schedule,100% of FL Medicaid rate,196.47,398.86,
RIBS 4 VW BILAT INC PA CHEST PRO FEE,5840486,CDM,972,RC,71111,HCPCS,Outpatient,,,54.59,27.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,55.64,110,,,Fee Schedule,110% of Multiplan Fee Schedule,55.64,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,63.98,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,78.64,100,,,Case Rate,Pays Based on per visit rate,26.04,100,,,Fee Schedule,100% of FL Medicaid Rate,26.04,100,,,Fee Schedule,100% of FL Medicaid rate,26.04,176.4,
US VASC NEEDLE GUIDE PRO FEE,5840487,CDM,972,RC,76937,HCPCS,Outpatient,,,133.9,66.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,40.99,110,,,Fee Schedule,110% of Multiplan Fee Schedule,40.99,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,47.13,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,69.87,100,,,Case Rate,Pays Based on per visit rate,17.27,100,,,Fee Schedule,100% of FL Medicaid Rate,17.27,100,,,Fee Schedule,100% of FL Medicaid rate,17.27,176.4,
US BLADDER ONLY POST VOID PROFEE,5840488,CDM,972,RC,51798,HCPCS,Outpatient,,,53.56,26.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,11.88,110,,,Fee Schedule,110% of Multiplan Fee Schedule,11.88,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,13.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,60.5,100,,,Case Rate,Pays Based on per visit rate,7.9,100,,,Fee Schedule,100% of FL Medicaid Rate,7.9,100,,,Fee Schedule,100% of FL Medicaid rate,7.9,60.5,
US PELVIC LIMITED NON OB PRO FEE,5840489,CDM,972,RC,76857,HCPCS,Outpatient,,,75.71,37.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,52.59,110,,,Fee Schedule,110% of Multiplan Fee Schedule,52.59,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,60.48,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,85.3,100,,,Case Rate,Pays Based on per visit rate,32.7,100,,,Fee Schedule,100% of FL Medicaid Rate,32.7,100,,,Fee Schedule,100% of FL Medicaid rate,32.7,176.4,
CT CHEST LOW DOSE PRO FEE,5840490,CDM,972,RC,71271,HCPCS,Outpatient,,,314.97,157.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,149.46,110,,,Fee Schedule,110% of Multiplan Fee Schedule,149.46,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,171.88,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,176.4,100,,,Case Rate,Pays Based on Per visit rate,146.23,100,,,Case Rate,Pays Based on per visit rate,93.63,100,,,Fee Schedule,100% of FL Medicaid Rate,93.63,100,,,Fee Schedule,100% of FL Medicaid rate,93.63,176.4,
PT GAIT TRAINING/15M,6100001,CDM,420,RC,97116,HCPCS,Outpatient,,,98.88,49.44,,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,67.24,68,,53.792,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,82,
PT THRPTC EX 15 MIN,6100003,CDM,420,RC,97110,HCPCS,Outpatient,,,109.18,54.59,,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,74.24,68,,59.392,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,82,
PT NEUROMUSC RE-ED/15M,6100005,CDM,420,RC,97112,HCPCS,Outpatient,,,109.18,54.59,,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,74.24,68,,59.392,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,21.84,20,,17.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,70.97,65,,56.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,82,
PT ORTHOTIC FT TR Q15M,6100007,CDM,420,RC,97760,HCPCS,Outpatient,,,113.3,56.65,,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,77.04,68,,61.632,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,82,
PT ULTRASOUND/15M,6100011,CDM,420,RC,97035,HCPCS,Outpatient,,,90.64,45.32,,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,61.64,68,,49.312,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,18.13,20,,14.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,58.92,65,,47.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.13,82,
CONSTANT ATTENDANCE THERAPY,6100012,CDM,420,RC,97037,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,82,
PT ELECTRIC STIMULATION,6100013,CDM,420,RC,G0283,HCPCS,Outpatient,,,99.91,49.96,,64.94,65,,51.952,Percent of Total Billed Charges,65% of Total Billed Charges,67.94,68,,54.352,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,20,,15.984,Percent of Total Billed Charges,20% of Total Billed Charges,19.98,20,,15.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,20,,15.984,Percent of Total Billed Charges,20% of Total Billed Charges,19.98,20,,15.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.94,65,,51.952,Percent of Total Billed Charges,65% of Total Billed Charges,64.94,65,,51.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.98,82,
LASER THERAPY CONSTANT,6100014,CDM,420,RC,97039,HCPCS,Outpatient,,,50,25.00,,32.5,65,,26,Percent of Total Billed Charges,65% of Total Billed Charges,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,20,,8,Percent of Total Billed Charges,20% of Total Billed Charges,10,20,,8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,20,,8,Percent of Total Billed Charges,20% of Total Billed Charges,10,20,,8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,65,,26,Percent of Total Billed Charges,65% of Total Billed Charges,32.5,65,,26,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,82,
PT THERAPEUTIC ACTIVITY,6100015,CDM,420,RC,97530,HCPCS,Outpatient,,,104.03,52.02,,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,70.74,68,,56.592,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,82,
LASER THERAPY CONSTANT PKG 5,6100016,CDM,420,RC,97039,HCPCS,Outpatient,,,200,100.00,,130,65,,104,Percent of Total Billed Charges,65% of Total Billed Charges,136,68,,108.8,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,20,,32,Percent of Total Billed Charges,20% of Total Billed Charges,40,20,,32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,20,,32,Percent of Total Billed Charges,20% of Total Billed Charges,40,20,,32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,65,,104,Percent of Total Billed Charges,65% of Total Billed Charges,130,65,,104,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,136,
PT PROSTHETIC TR Q15MIN,6100017,CDM,420,RC,97761,HCPCS,Outpatient,,,113.3,56.65,,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,77.04,68,,61.632,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,82,
LASER THERAPY CONSTANT PKG 10,6100018,CDM,420,RC,97039,HCPCS,Outpatient,,,400,200.00,,260,65,,208,Percent of Total Billed Charges,65% of Total Billed Charges,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,20,,64,Percent of Total Billed Charges,20% of Total Billed Charges,80,20,,64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,20,,64,Percent of Total Billed Charges,20% of Total Billed Charges,80,20,,64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260,65,,208,Percent of Total Billed Charges,65% of Total Billed Charges,260,65,,208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,272,
PT PARAFFIN BATH,6100019,CDM,420,RC,97018,HCPCS,Outpatient,,,63.86,31.93,,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,43.42,68,,34.736,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,12.77,20,,10.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,41.51,65,,33.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,82,
PT MANUAL THERAPY/15M,6100021,CDM,420,RC,97140,HCPCS,Outpatient,,,121.54,60.77,,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,82.65,68,,66.12,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,24.31,20,,19.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,79,65,,63.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.31,82.65,
PT EVALUATION LOW COMPLEXITY,6100023,CDM,424,RC,97161,HCPCS,Outpatient,,,299.73,149.87,,194.82,65,,155.856,Percent of Total Billed Charges,65% of Total Billed Charges,203.82,68,,163.056,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.82,65,,155.856,Percent of Total Billed Charges,65% of Total Billed Charges,194.82,65,,155.856,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,203.82,
PT RE EVALUATION,6100025,CDM,424,RC,97164,HCPCS,Outpatient,,,150.38,75.19,,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,102.26,68,,81.808,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,102.26,
PT EVALUATION MODERATE COMPLEXITY,6100089,CDM,424,RC,97162,HCPCS,Outpatient,,,351.23,175.62,,228.3,65,,182.64,Percent of Total Billed Charges,65% of Total Billed Charges,238.84,68,,191.072,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.25,20,,56.2,Percent of Total Billed Charges,20% of Total Billed Charges,70.25,20,,56.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.25,20,,56.2,Percent of Total Billed Charges,20% of Total Billed Charges,70.25,20,,56.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.3,65,,182.64,Percent of Total Billed Charges,65% of Total Billed Charges,228.3,65,,182.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,238.84,
PT EVALUATION HIGH COMPLEXITY,6100090,CDM,424,RC,97163,HCPCS,Outpatient,,,402.73,201.37,,261.77,65,,209.416,Percent of Total Billed Charges,65% of Total Billed Charges,273.86,68,,219.088,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.55,20,,64.44,Percent of Total Billed Charges,20% of Total Billed Charges,80.55,20,,64.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.55,20,,64.44,Percent of Total Billed Charges,20% of Total Billed Charges,80.55,20,,64.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.77,65,,209.416,Percent of Total Billed Charges,65% of Total Billed Charges,261.77,65,,209.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,273.86,
PT MANUAL THERAPY,6100094,CDM,420,RC,97140,HCPCS,Outpatient,,,113.3,56.65,,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,77.04,68,,61.632,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,22.66,20,,18.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,73.65,65,,58.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,82,
TEST THRPTC EX 30 MIN,6155555,CDM,420,RC,97110,HCPCS,Outpatient,,,257.5,128.75,,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,175.1,68,,140.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,175.1,
=>PT ORDER<=,6190001,CDM,420,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,82,
=>CANCEL REHAB ORDER<=,6190002,CDM,420,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,82,
OT EVALUATION LOW COMPLEXITY,6200027,CDM,434,RC,97165,HCPCS,Outpatient,,,210.12,105.06,,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,142.88,68,,114.304,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,42.02,20,,33.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,136.58,65,,109.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,142.88,
OT NEURO RE EDUCA,6200029,CDM,430,RC,97112,HCPCS,Outpatient,,,104.03,52.02,,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,70.74,68,,56.592,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,82,
OT THERAPEUTIC EX,6200031,CDM,430,RC,97110,HCPCS,Outpatient,,,64.89,32.45,,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,44.13,68,,35.304,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,12.98,20,,10.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,42.18,65,,33.744,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.98,82,
OT ACTIVITIES OF DAILY LIVING EVAL/TREAT,6200033,CDM,430,RC,97530,HCPCS,Outpatient,,,97.85,48.93,,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,66.54,68,,53.232,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,82,
OT SELF MNG TRAIN/15 MIN,6200035,CDM,430,RC,97535,HCPCS,Outpatient,,,103,51.50,,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,70.04,68,,56.032,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,20.6,20,,16.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,66.95,65,,53.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.6,82,
OT W/C MGMT TRAINING,6200046,CDM,430,RC,97542,HCPCS,Outpatient,,,66.95,33.48,,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,45.53,68,,36.424,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,13.39,20,,10.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,43.52,65,,34.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,82,
OT EVALUATION MODERATECOMPLEXITY,6200091,CDM,434,RC,97166,HCPCS,Outpatient,,,261.62,130.81,,170.05,65,,136.04,Percent of Total Billed Charges,65% of Total Billed Charges,177.9,68,,142.32,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.32,20,,41.856,Percent of Total Billed Charges,20% of Total Billed Charges,52.32,20,,41.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.32,20,,41.856,Percent of Total Billed Charges,20% of Total Billed Charges,52.32,20,,41.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.05,65,,136.04,Percent of Total Billed Charges,65% of Total Billed Charges,170.05,65,,136.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.32,177.9,
OT EVALUATION HIGH COMPLEXITY,6200092,CDM,434,RC,97167,HCPCS,Outpatient,,,313.12,156.56,,203.53,65,,162.824,Percent of Total Billed Charges,65% of Total Billed Charges,212.92,68,,170.336,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.62,20,,50.096,Percent of Total Billed Charges,20% of Total Billed Charges,62.62,20,,50.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.62,20,,50.096,Percent of Total Billed Charges,20% of Total Billed Charges,62.62,20,,50.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.53,65,,162.824,Percent of Total Billed Charges,65% of Total Billed Charges,203.53,65,,162.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,212.92,
OT RE-EVALUATION,6200093,CDM,434,RC,97168,HCPCS,Outpatient,,,150.38,75.19,,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,102.26,68,,81.808,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,102.26,
OT THERAPEUTIC ACTIV,6210033,CDM,430,RC,97530,HCPCS,Outpatient,,,97.85,48.93,,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,66.54,68,,53.232,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,19.57,20,,15.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,63.6,65,,50.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.57,82,
=>OT ORDER<=,6290001,CDM,430,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,82,
ST EVAL OF SPEECH FLUENCY,6300037,CDM,444,RC,92521,HCPCS,Outpatient,,,174.07,87.04,,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,118.37,68,,94.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,118.37,
ST SPEECH AND HEARING THERAPY,6300039,CDM,440,RC,92507,HCPCS,Outpatient,,,108.15,54.08,,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,73.54,68,,58.832,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,21.63,20,,17.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,70.3,65,,56.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,82,
ST SWALLOWING EVALUATION,6300041,CDM,444,RC,92610,HCPCS,Outpatient,,,123.6,61.80,,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,84.05,68,,67.24,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,84.05,
ST SWALLOWING THERAPY,6300043,CDM,440,RC,92526,HCPCS,Outpatient,,,98.88,49.44,,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,67.24,68,,53.792,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,19.78,20,,15.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,64.27,65,,51.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,82,
ST COGNITIVE SKILLS DEV,6300045,CDM,440,RC,G0515,HCPCS,Outpatient,,,80.34,40.17,,52.22,65,,41.776,Percent of Total Billed Charges,65% of Total Billed Charges,54.63,68,,43.704,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,20,,12.856,Percent of Total Billed Charges,20% of Total Billed Charges,16.07,20,,12.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,20,,12.856,Percent of Total Billed Charges,20% of Total Billed Charges,16.07,20,,12.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.22,65,,41.776,Percent of Total Billed Charges,65% of Total Billed Charges,52.22,65,,41.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,82,
ST EVAL OF SPEECH SOUND PRODUCTION,6300095,CDM,440,RC,92522,HCPCS,Outpatient,,,174.07,87.04,,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,118.37,68,,94.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,118.37,
ST EVAL SOUND PROD W/EVL LANG COMP&EXPR,6300096,CDM,440,RC,92523,HCPCS,Outpatient,,,174.07,87.04,,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,118.37,68,,94.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,118.37,
ST BEHAV/QUAL ANALYS VOICE&RESONANCE,6300097,CDM,440,RC,92524,HCPCS,Outpatient,,,174.07,87.04,,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,118.37,68,,94.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,34.81,20,,27.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,113.15,65,,90.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,118.37,
=>ST ORDER<=,6390001,CDM,440,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,,Case Rate,Pays Based on Per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,82,
OXYGEN USAGE HOUR,6410011,CDM,270,RC,,,Outpatient,,,54.28,27.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.86,20,,8.688,Percent of Total Billed Charges,20% of Total Billed Charges,10.86,20,,8.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.86,20,,8.688,Percent of Total Billed Charges,20% of Total Billed Charges,10.86,20,,8.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.28,65,,28.224,Percent of Total Billed Charges,65% of Total Billed Charges,35.28,65,,28.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.86,53.67,
NOTIFY RESPIRATORY,6410019,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OXYGEN,6410020,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
do not use,6410021,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CPR,6420097,CDM,480,RC,92950,HCPCS,Outpatient,,,546.98,273.49,,355.54,65,,284.432,Percent of Total Billed Charges,65% of Total Billed Charges,371.95,68,,297.56,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.4,20,,87.52,Percent of Total Billed Charges,20% of Total Billed Charges,109.4,20,,87.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.4,20,,87.52,Percent of Total Billed Charges,20% of Total Billed Charges,109.4,20,,87.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.54,65,,284.432,Percent of Total Billed Charges,65% of Total Billed Charges,355.54,65,,284.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,371.95,
BRONCHODILATOR,6470001,CDM,250,RC,,,Outpatient,,,2.06,1.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,0.41,20,,0.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,1.34,65,,1.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,53.67,
do not use,6470009,CDM,250,RC,,,Outpatient,,,18.54,9.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,20,,2.968,Percent of Total Billed Charges,20% of Total Billed Charges,3.71,20,,2.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,20,,2.968,Percent of Total Billed Charges,20% of Total Billed Charges,3.71,20,,2.968,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,65,,9.64,Percent of Total Billed Charges,65% of Total Billed Charges,12.05,65,,9.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,53.67,
CONN TUBING OXYGEN,6470015,CDM,271,RC,,,Outpatient,,,2.83,1.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,20,,0.456,Percent of Total Billed Charges,20% of Total Billed Charges,0.57,20,,0.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,20,,0.456,Percent of Total Billed Charges,20% of Total Billed Charges,0.57,20,,0.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,65,,1.472,Percent of Total Billed Charges,65% of Total Billed Charges,1.84,65,,1.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,53.67,
CIRCUIT VENTILATOR,6470017,CDM,271,RC,,,Outpatient,,,123.6,61.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,24.72,20,,19.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,80.34,65,,64.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,80.34,
CIRCUIT NEBULIZER,6470019,CDM,271,RC,,,Outpatient,,,7.73,3.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,20,,1.24,Percent of Total Billed Charges,20% of Total Billed Charges,1.55,20,,1.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,20,,1.24,Percent of Total Billed Charges,20% of Total Billed Charges,1.55,20,,1.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,65,,4.016,Percent of Total Billed Charges,65% of Total Billed Charges,5.02,65,,4.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,53.67,
SUCTION MACH BOTL,6470021,CDM,271,RC,,,Outpatient,,,53.51,26.76,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.7,20,,8.56,Percent of Total Billed Charges,20% of Total Billed Charges,10.7,20,,8.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.7,20,,8.56,Percent of Total Billed Charges,20% of Total Billed Charges,10.7,20,,8.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.78,65,,27.824,Percent of Total Billed Charges,65% of Total Billed Charges,34.78,65,,27.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.7,53.67,
HUMIDIFIER NEBULIZER,6470023,CDM,272,RC,,,Outpatient,,,30.39,15.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.08,20,,4.864,Percent of Total Billed Charges,20% of Total Billed Charges,6.08,20,,4.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.08,20,,4.864,Percent of Total Billed Charges,20% of Total Billed Charges,6.08,20,,4.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.75,65,,15.8,Percent of Total Billed Charges,65% of Total Billed Charges,19.75,65,,15.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.08,53.67,
AIRWAY NASAL,6470025,CDM,272,RC,,,Outpatient,,,30.9,15.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,53.67,
AIRWAY ORAL,6470027,CDM,272,RC,,,Outpatient,,,30.9,15.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,6.18,20,,4.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,20.09,65,,16.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,53.67,
ET TUBE,6470029,CDM,272,RC,,,Outpatient,,,37.08,18.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,7.42,20,,5.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,24.1,65,,19.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,53.67,
RT- SPECIMEN TRAP,6470031,CDM,272,RC,,,Outpatient,,,10.92,5.46,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.18,20,,1.744,Percent of Total Billed Charges,20% of Total Billed Charges,2.18,20,,1.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.18,20,,1.744,Percent of Total Billed Charges,20% of Total Billed Charges,2.18,20,,1.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.1,65,,5.68,Percent of Total Billed Charges,65% of Total Billed Charges,7.1,65,,5.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.18,53.67,
SUCTION CATH,6470033,CDM,272,RC,,,Outpatient,,,4.27,2.14,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,20,,0.68,Percent of Total Billed Charges,20% of Total Billed Charges,0.85,20,,0.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,20,,0.68,Percent of Total Billed Charges,20% of Total Billed Charges,0.85,20,,0.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,65,,2.224,Percent of Total Billed Charges,65% of Total Billed Charges,2.78,65,,2.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,53.67,
INCENTIVE SPIROMETER,6470035,CDM,272,RC,,,Outpatient,,,38.11,19.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,7.62,20,,6.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,24.77,65,,19.816,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,53.67,
BAG MASK VENTILATION-ADULT,6470049,CDM,272,RC,,,Outpatient,,,107.74,53.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.55,20,,17.24,Percent of Total Billed Charges,20% of Total Billed Charges,21.55,20,,17.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.55,20,,17.24,Percent of Total Billed Charges,20% of Total Billed Charges,21.55,20,,17.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.03,65,,56.024,Percent of Total Billed Charges,65% of Total Billed Charges,70.03,65,,56.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.55,70.03,
PEAK FLOW METER,6470051,CDM,272,RC,,,Outpatient,,,153.47,76.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.69,20,,24.552,Percent of Total Billed Charges,20% of Total Billed Charges,30.69,20,,24.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.69,20,,24.552,Percent of Total Billed Charges,20% of Total Billed Charges,30.69,20,,24.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.76,65,,79.808,Percent of Total Billed Charges,65% of Total Billed Charges,99.76,65,,79.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.69,99.76,
INFANT CHILD AMBU,6470055,CDM,272,RC,,,Outpatient,,,72.62,36.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.52,20,,11.616,Percent of Total Billed Charges,20% of Total Billed Charges,14.52,20,,11.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.52,20,,11.616,Percent of Total Billed Charges,20% of Total Billed Charges,14.52,20,,11.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.2,65,,37.76,Percent of Total Billed Charges,65% of Total Billed Charges,47.2,65,,37.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.52,53.67,
ADLT TRACHEOSTOMY TB,6470063,CDM,272,RC,,,Outpatient,,,253.79,126.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.76,20,,40.608,Percent of Total Billed Charges,20% of Total Billed Charges,50.76,20,,40.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.76,20,,40.608,Percent of Total Billed Charges,20% of Total Billed Charges,50.76,20,,40.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.96,65,,131.968,Percent of Total Billed Charges,65% of Total Billed Charges,164.96,65,,131.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.76,164.96,
ABG ANALYSIS,6470067,CDM,301,RC,82803,HCPCS,Outpatient,,,298.7,149.35,,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,203.12,68,,162.496,Percent of Total Billed Charges,68% of Total Billed Charges,27.47,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,59.74,20,,47.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,194.16,65,,155.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.35,50,,119.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.47,203.12,
ABG DRAW,6470068,CDM,301,RC,36600,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,178,
NEB/MDI SUB-IP/SB/HOSPICE,6470069,CDM,410,RC,94640,HCPCS,Outpatient,,,632.47,316.24,,411.11,65,,328.888,Percent of Total Billed Charges,65% of Total Billed Charges,430.08,68,,344.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.49,20,,101.192,Percent of Total Billed Charges,20% of Total Billed Charges,126.49,20,,101.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.49,20,,101.192,Percent of Total Billed Charges,20% of Total Billed Charges,126.49,20,,101.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.11,65,,328.888,Percent of Total Billed Charges,65% of Total Billed Charges,411.11,65,,328.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,430.08,
HOME CPAP MANAGEMENT,6470070,CDM,410,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,74,
CPT CHEST PD SUB,6470071,CDM,410,RC,94668,HCPCS,Outpatient,,,257.5,128.75,,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,175.1,68,,140.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,175.1,
do not use,6470072,CDM,410,RC,94640,HCPCS,Outpatient,,,153.94,76.97,,100.06,65,,80.048,Percent of Total Billed Charges,65% of Total Billed Charges,104.68,68,,83.744,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.79,20,,24.632,Percent of Total Billed Charges,20% of Total Billed Charges,30.79,20,,24.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.79,20,,24.632,Percent of Total Billed Charges,20% of Total Billed Charges,30.79,20,,24.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.06,65,,80.048,Percent of Total Billed Charges,65% of Total Billed Charges,100.06,65,,80.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.79,104.68,
CPT & PD INT,6470073,CDM,410,RC,94667,HCPCS,Outpatient,,,257.5,128.75,,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,175.1,68,,140.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,175.1,
do not use,6470074,CDM,410,RC,94640,HCPCS,Outpatient,,,153.94,76.97,,100.06,65,,80.048,Percent of Total Billed Charges,65% of Total Billed Charges,104.68,68,,83.744,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.79,20,,24.632,Percent of Total Billed Charges,20% of Total Billed Charges,30.79,20,,24.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.79,20,,24.632,Percent of Total Billed Charges,20% of Total Billed Charges,30.79,20,,24.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.06,65,,80.048,Percent of Total Billed Charges,65% of Total Billed Charges,100.06,65,,80.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.79,104.68,
VENTILATOR/INIT/DAY,6470075,CDM,410,RC,94002,HCPCS,Outpatient,,,1545,772.50,,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,1050.6,68,,840.48,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,309,20,,247.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,1004.25,65,,803.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1050.6,
ET CO2 NASAL CANNULA,6470076,CDM,460,RC,A4615,HCPCS,Outpatient,,,205.39,102.70,,133.5,65,,106.8,Percent of Total Billed Charges,65% of Total Billed Charges,139.67,68,,111.736,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.08,20,,32.864,Percent of Total Billed Charges,20% of Total Billed Charges,41.08,20,,32.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.08,20,,32.864,Percent of Total Billed Charges,20% of Total Billed Charges,41.08,20,,32.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,65,,106.8,Percent of Total Billed Charges,65% of Total Billed Charges,133.5,65,,106.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.08,207,
do not use,6470077,CDM,410,RC,94640,HCPCS,Outpatient,,,224.33,112.17,,145.81,65,,116.648,Percent of Total Billed Charges,65% of Total Billed Charges,152.54,68,,122.032,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.87,20,,35.896,Percent of Total Billed Charges,20% of Total Billed Charges,44.87,20,,35.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.87,20,,35.896,Percent of Total Billed Charges,20% of Total Billed Charges,44.87,20,,35.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.81,65,,116.648,Percent of Total Billed Charges,65% of Total Billed Charges,145.81,65,,116.648,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.87,152.54,
VENT USAGE/ SUB/DA,6470079,CDM,410,RC,94003,HCPCS,Outpatient,,,934.88,467.44,,607.67,65,,486.136,Percent of Total Billed Charges,65% of Total Billed Charges,635.72,68,,508.576,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.98,20,,149.584,Percent of Total Billed Charges,20% of Total Billed Charges,186.98,20,,149.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.98,20,,149.584,Percent of Total Billed Charges,20% of Total Billed Charges,186.98,20,,149.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,607.67,65,,486.136,Percent of Total Billed Charges,65% of Total Billed Charges,607.67,65,,486.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,635.72,
SPUTUM COLLECTION,6470081,CDM,410,RC,89220,HCPCS,Outpatient,,,139.32,69.66,,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,94.74,68,,75.792,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.86,94.74,
CPAP/BIPAP INITIAL,6470082,CDM,410,RC,94660,HCPCS,Outpatient,,,606.67,303.34,,394.34,65,,315.472,Percent of Total Billed Charges,65% of Total Billed Charges,412.54,68,,330.032,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.33,20,,97.064,Percent of Total Billed Charges,20% of Total Billed Charges,121.33,20,,97.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.33,20,,97.064,Percent of Total Billed Charges,20% of Total Billed Charges,121.33,20,,97.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,394.34,65,,315.472,Percent of Total Billed Charges,65% of Total Billed Charges,394.34,65,,315.472,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,412.54,
MDI INHALER EVAL,6470083,CDM,410,RC,94664,HCPCS,Outpatient,,,206,103.00,,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,140.08,68,,112.064,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,140.08,
SUB CPAP-BIPAP,6470084,CDM,410,RC,94662,HCPCS,Outpatient,,,758.08,379.04,,492.75,65,,394.2,Percent of Total Billed Charges,65% of Total Billed Charges,515.49,68,,412.392,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.62,20,,121.296,Percent of Total Billed Charges,20% of Total Billed Charges,151.62,20,,121.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.62,20,,121.296,Percent of Total Billed Charges,20% of Total Billed Charges,151.62,20,,121.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.75,65,,394.2,Percent of Total Billed Charges,65% of Total Billed Charges,492.75,65,,394.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,515.49,
NEB MDI SPUTUM SUB,6470085,CDM,410,RC,94640,HCPCS,Outpatient,,,139.32,69.66,,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,94.74,68,,75.792,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.86,94.74,
INTUBATION,6470089,CDM,450,RC,31500,HCPCS,Outpatient,,,515,257.50,,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,350.2,68,,280.16,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,350.2,
PFT SIMPLE,6470091,CDM,460,RC,94010,HCPCS,Outpatient,,,334.75,167.38,,217.59,65,,174.072,Percent of Total Billed Charges,65% of Total Billed Charges,227.63,68,,182.104,Percent of Total Billed Charges,68% of Total Billed Charges,14.22,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,66.95,20,,53.56,Percent of Total Billed Charges,20% of Total Billed Charges,66.95,20,,53.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.95,20,,53.56,Percent of Total Billed Charges,20% of Total Billed Charges,66.95,20,,53.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.59,65,,174.072,Percent of Total Billed Charges,65% of Total Billed Charges,217.59,65,,174.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.22,227.63,
PFT TOTAL,6470095,CDM,460,RC,94060,HCPCS,Outpatient,,,437.75,218.88,,284.54,65,,227.632,Percent of Total Billed Charges,65% of Total Billed Charges,297.67,68,,238.136,Percent of Total Billed Charges,68% of Total Billed Charges,31.31,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,87.55,20,,70.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.54,65,,227.632,Percent of Total Billed Charges,65% of Total Billed Charges,284.54,65,,227.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.31,297.67,
EXERCISE PULSE OX,6470096,CDM,460,RC,94618,HCPCS,Outpatient,,,206,103.00,,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,140.08,68,,112.064,Percent of Total Billed Charges,68% of Total Billed Charges,47.93,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,41.2,20,,32.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,133.9,65,,107.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.2,207,
do not use,6470098,CDM,410,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,74,
TRACH REPLACEMENT,6470099,CDM,410,RC,31502,HCPCS,Outpatient,,,154.5,77.25,,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,105.06,68,,84.048,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,30.9,20,,24.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,100.43,65,,80.344,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,178,
LAB BLOOD DRAW (RESP),6470100,CDM,301,RC,36600,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,178,
NASO/TRACH SUCTION,6470101,CDM,410,RC,31720,HCPCS,Outpatient,,,139.32,69.66,,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,94.74,68,,75.792,Percent of Total Billed Charges,68% of Total Billed Charges,312,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,27.86,20,,22.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,90.56,65,,72.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.86,312,
PULM STRESS TEST/SIMPLE,6470105,CDM,460,RC,94618,HCPCS,Outpatient,,,134.93,67.47,,87.7,65,,70.16,Percent of Total Billed Charges,65% of Total Billed Charges,91.75,68,,73.4,Percent of Total Billed Charges,68% of Total Billed Charges,47.93,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,26.99,20,,21.592,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.7,65,,70.16,Percent of Total Billed Charges,65% of Total Billed Charges,87.7,65,,70.16,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.99,207,
CONT INHALATION TX 1ST HOUR,6470106,CDM,410,RC,94644,HCPCS,Outpatient,,,618,309.00,,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,420.24,68,,336.192,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,123.6,20,,98.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,401.7,65,,321.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,420.24,
SUCTION TUBING,6470110,CDM,272,RC,,,Outpatient,,,6.83,3.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,20,,1.096,Percent of Total Billed Charges,20% of Total Billed Charges,1.37,20,,1.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,20,,1.096,Percent of Total Billed Charges,20% of Total Billed Charges,1.37,20,,1.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.44,65,,3.552,Percent of Total Billed Charges,65% of Total Billed Charges,4.44,65,,3.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,53.67,
MED NON-VENTED BIPAP/CPAP MASK,6470111,CDM,272,RC,,,Outpatient,,,158.91,79.46,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.78,20,,25.424,Percent of Total Billed Charges,20% of Total Billed Charges,31.78,20,,25.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.78,20,,25.424,Percent of Total Billed Charges,20% of Total Billed Charges,31.78,20,,25.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.29,65,,82.632,Percent of Total Billed Charges,65% of Total Billed Charges,103.29,65,,82.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.78,103.29,
LG NON-VENTED BIPAP/CPAP MASK,6470112,CDM,272,RC,,,Outpatient,,,158.91,79.46,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.78,20,,25.424,Percent of Total Billed Charges,20% of Total Billed Charges,31.78,20,,25.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.78,20,,25.424,Percent of Total Billed Charges,20% of Total Billed Charges,31.78,20,,25.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.29,65,,82.632,Percent of Total Billed Charges,65% of Total Billed Charges,103.29,65,,82.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.78,103.29,
INTUBATION BLADES,6470113,CDM,272,RC,,,Outpatient,,,47.42,23.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,9.48,20,,7.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.82,65,,24.656,Percent of Total Billed Charges,65% of Total Billed Charges,30.82,65,,24.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,53.67,
INTUBATION STYLET,6470114,CDM,272,RC,,,Outpatient,,,9.59,4.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,20,,1.536,Percent of Total Billed Charges,20% of Total Billed Charges,1.92,20,,1.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,20,,1.536,Percent of Total Billed Charges,20% of Total Billed Charges,1.92,20,,1.536,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.23,65,,4.984,Percent of Total Billed Charges,65% of Total Billed Charges,6.23,65,,4.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,53.67,
ET TUBE HOLDER,6470115,CDM,272,RC,,,Outpatient,,,19,9.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,53.67,
KING TUBE SIZE 4,6470116,CDM,272,RC,,,Outpatient,,,87.1,43.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.42,20,,13.936,Percent of Total Billed Charges,20% of Total Billed Charges,17.42,20,,13.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.42,20,,13.936,Percent of Total Billed Charges,20% of Total Billed Charges,17.42,20,,13.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.62,65,,45.296,Percent of Total Billed Charges,65% of Total Billed Charges,56.62,65,,45.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.42,56.62,
ADULT COLORIMETRIC CO2 DETECTOR,6470117,CDM,272,RC,,,Outpatient,,,97.27,48.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.45,20,,15.56,Percent of Total Billed Charges,20% of Total Billed Charges,19.45,20,,15.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.45,20,,15.56,Percent of Total Billed Charges,20% of Total Billed Charges,19.45,20,,15.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.23,65,,50.584,Percent of Total Billed Charges,65% of Total Billed Charges,63.23,65,,50.584,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.45,63.23,
ACAPELLA SECRETN CLEARANCE DEVICE(GREEN),6470118,CDM,272,RC,,,Outpatient,,,217.88,108.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.58,20,,34.864,Percent of Total Billed Charges,20% of Total Billed Charges,43.58,20,,34.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.58,20,,34.864,Percent of Total Billed Charges,20% of Total Billed Charges,43.58,20,,34.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.62,65,,113.296,Percent of Total Billed Charges,65% of Total Billed Charges,141.62,65,,113.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.58,141.62,
do not use,6470119,CDM,410,RC,94645,HCPCS,Outpatient,,,194.87,97.44,,126.67,65,,101.336,Percent of Total Billed Charges,65% of Total Billed Charges,132.51,68,,106.008,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.97,20,,31.176,Percent of Total Billed Charges,20% of Total Billed Charges,38.97,20,,31.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.97,20,,31.176,Percent of Total Billed Charges,20% of Total Billed Charges,38.97,20,,31.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.67,65,,101.336,Percent of Total Billed Charges,65% of Total Billed Charges,126.67,65,,101.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.97,132.51,
CPAP/BIPAP SUB,6470120,CDM,410,RC,94660,HCPCS,Outpatient,,,493.37,246.69,,320.69,65,,256.552,Percent of Total Billed Charges,65% of Total Billed Charges,335.49,68,,268.392,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,20,,78.936,Percent of Total Billed Charges,20% of Total Billed Charges,98.67,20,,78.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,20,,78.936,Percent of Total Billed Charges,20% of Total Billed Charges,98.67,20,,78.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.69,65,,256.552,Percent of Total Billed Charges,65% of Total Billed Charges,320.69,65,,256.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,335.49,
EXHALED CO2,6470121,CDM,460,RC,94681,HCPCS,Outpatient,,,205.39,102.70,,133.5,65,,106.8,Percent of Total Billed Charges,65% of Total Billed Charges,139.67,68,,111.736,Percent of Total Billed Charges,68% of Total Billed Charges,48.41,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,41.08,20,,32.864,Percent of Total Billed Charges,20% of Total Billed Charges,41.08,20,,32.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.08,20,,32.864,Percent of Total Billed Charges,20% of Total Billed Charges,41.08,20,,32.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,65,,106.8,Percent of Total Billed Charges,65% of Total Billed Charges,133.5,65,,106.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.08,207,
=>CANCEL RESPIRATORY ORDER<=,6490001,CDM,410,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,74,
RT EVALUATION AND TREATMENT,6490002,CDM,410,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,100,,,Case Rate,Pays Based on Per visit rate,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,74,
APPLY COMPRES BELOW KNEE/FOOT,8000062,CDM,510,RC,29581,HCPCS,Outpatient,,,278.1,139.05,,180.77,65,,144.616,Percent of Total Billed Charges,65% of Total Billed Charges,189.11,68,,151.288,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.62,20,,44.496,Percent of Total Billed Charges,20% of Total Billed Charges,55.62,20,,44.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.62,20,,44.496,Percent of Total Billed Charges,20% of Total Billed Charges,55.62,20,,44.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.77,65,,144.616,Percent of Total Billed Charges,65% of Total Billed Charges,180.77,65,,144.616,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,189.11,
LEVEL 1 NEW PT,8000063,CDM,510,RC,,,Outpatient,,,152.44,76.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,30.49,20,,24.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.09,65,,79.272,Percent of Total Billed Charges,65% of Total Billed Charges,99.09,65,,79.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.49,99.09,
APPLY MULTI COMP LOWER LEG,8000064,CDM,510,RC,29581,HCPCS,Outpatient,,,138.02,69.01,,89.71,65,,71.768,Percent of Total Billed Charges,65% of Total Billed Charges,93.85,68,,75.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.71,65,,71.768,Percent of Total Billed Charges,65% of Total Billed Charges,89.71,65,,71.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.6,178,
LEVEL 2 NEW PT,8000065,CDM,510,RC,99202,HCPCS,Outpatient,,,253.38,126.69,,164.7,65,,131.76,Percent of Total Billed Charges,65% of Total Billed Charges,172.3,68,,137.84,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.68,20,,40.544,Percent of Total Billed Charges,20% of Total Billed Charges,50.68,20,,40.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.68,20,,40.544,Percent of Total Billed Charges,20% of Total Billed Charges,50.68,20,,40.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.7,65,,131.76,Percent of Total Billed Charges,65% of Total Billed Charges,164.7,65,,131.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.68,172.3,
LEVEL 3 NEW PT,8000067,CDM,510,RC,99203,HCPCS,Outpatient,,,359.47,179.74,,233.66,65,,186.928,Percent of Total Billed Charges,65% of Total Billed Charges,244.44,68,,195.552,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.89,20,,57.512,Percent of Total Billed Charges,20% of Total Billed Charges,71.89,20,,57.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.89,20,,57.512,Percent of Total Billed Charges,20% of Total Billed Charges,71.89,20,,57.512,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.66,65,,186.928,Percent of Total Billed Charges,65% of Total Billed Charges,233.66,65,,186.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,244.44,
LEVEL 4 NEW PT PRO FEE,8000069,CDM,983,RC,99204,HCPCS,Outpatient,,,442.9,221.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,293.74,109,,,Fee Schedule,109% of Multiplan Fee Schedule,293.74,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,168.86,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,140.22,100,,,Case Rate,Pays Based on per visit rate,87.62,100,,,Fee Schedule,100% of FL Medicaid Rate,87.62,100,,,Fee Schedule,100% of FL Medicaid rate,87.62,293.74,
LEVEL 4 NEW PT,8000070,CDM,510,RC,99204,HCPCS,Outpatient,,,553.11,276.56,,359.52,65,,287.616,Percent of Total Billed Charges,65% of Total Billed Charges,376.11,68,,300.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.62,20,,88.496,Percent of Total Billed Charges,20% of Total Billed Charges,110.62,20,,88.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.62,20,,88.496,Percent of Total Billed Charges,20% of Total Billed Charges,110.62,20,,88.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.52,65,,287.616,Percent of Total Billed Charges,65% of Total Billed Charges,359.52,65,,287.616,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,376.11,
LEVEL 5 NEW PT,8000071,CDM,510,RC,99205,HCPCS,Outpatient,,,698.34,349.17,,453.92,65,,363.136,Percent of Total Billed Charges,65% of Total Billed Charges,474.87,68,,379.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.67,20,,111.736,Percent of Total Billed Charges,20% of Total Billed Charges,139.67,20,,111.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.67,20,,111.736,Percent of Total Billed Charges,20% of Total Billed Charges,139.67,20,,111.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.92,65,,363.136,Percent of Total Billed Charges,65% of Total Billed Charges,453.92,65,,363.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,474.87,
I & D DRAINAGE ABSCESS SIMPLE PRO CLINIC,8000072,CDM,983,RC,10060,HCPCS,Outpatient,,,323.42,161.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,115.94,110,,,Fee Schedule,110% of Multiplan Fee Schedule,115.94,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,133.33,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,121.3,100,,,Case Rate,Pays Based on per visit rate,68.7,100,,,Fee Schedule,100% of FL Medicaid Rate,68.7,100,,,Fee Schedule,100% of FL Medicaid rate,68.7,133.33,
LEVEL 1 EST PT PRO FEE,8000073,CDM,983,RC,99211,HCPCS,Outpatient,,,76.22,38.11,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,19.14,109,,,Fee Schedule,109% of Multiplan Fee Schedule,19.14,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,10.95,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,58.11,100,,,Case Rate,Pays Based on per visit rate,5.51,100,,,Fee Schedule,100% of FL Medicaid Rate,5.51,100,,,Fee Schedule,100% of FL Medicaid rate,5.51,58.11,
LEVEL 2 EST PT,8000075,CDM,510,RC,99212,HCPCS,Outpatient,,,150.38,75.19,,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,102.26,68,,81.808,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,30.08,20,,24.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,97.75,65,,78.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.08,102.26,
AVULSION NAIL PLATE/PARTCOMP SIMPLE PRO,8000076,CDM,983,RC,11732,HCPCS,Outpatient,,,66.95,33.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,18.6,110,,,Fee Schedule,110% of Multiplan Fee Schedule,18.6,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,21.39,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,64.37,100,,,Case Rate,Pays Based on per visit rate,11.77,100,,,Fee Schedule,100% of FL Medicaid Rate,11.77,100,,,Fee Schedule,100% of FL Medicaid rate,11.77,64.37,
LEVEL 3 EST PT,8000077,CDM,510,RC,99213,HCPCS,Outpatient,,,309,154.50,,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,210.12,68,,168.096,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,210.12,
LEVEL 4 EST PT,8000079,CDM,510,RC,99214,HCPCS,Outpatient,,,362.56,181.28,,235.66,65,,188.528,Percent of Total Billed Charges,65% of Total Billed Charges,246.54,68,,197.232,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.51,20,,58.008,Percent of Total Billed Charges,20% of Total Billed Charges,72.51,20,,58.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.51,20,,58.008,Percent of Total Billed Charges,20% of Total Billed Charges,72.51,20,,58.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.66,65,,188.528,Percent of Total Billed Charges,65% of Total Billed Charges,235.66,65,,188.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,246.54,
TRANS CARE MGMT 14 DAY DISCHARGE,8000080,CDM,983,RC,99495,HCPCS,Outpatient,,,120,60.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.8,109,,,Fee Schedule,109% of Multiplan Fee Schedule,262.8,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,151.8,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,262.8,
LEVEL 5 EST PT,8000081,CDM,510,RC,99215,HCPCS,Outpatient,,,488.22,244.11,,317.34,65,,253.872,Percent of Total Billed Charges,65% of Total Billed Charges,331.99,68,,265.592,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.64,20,,78.112,Percent of Total Billed Charges,20% of Total Billed Charges,97.64,20,,78.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.64,20,,78.112,Percent of Total Billed Charges,20% of Total Billed Charges,97.64,20,,78.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.34,65,,253.872,Percent of Total Billed Charges,65% of Total Billed Charges,317.34,65,,253.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,331.99,
TRANS CARE MGMT 7 DAY DISCHARGE,8000082,CDM,983,RC,99496,HCPCS,Outpatient,,,174,87.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,381.06,109,,,Fee Schedule,109% of Multiplan Fee Schedule,381.06,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,220.11,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,381.06,
VISIT COMPLEXITY,8000102,CDM,983,RC,G2211,HCPCS,Outpatient,,,16.04,8.02,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.64,110,,,Fee Schedule,110% of Multiplan Fee Schedule,17.64,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.29,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.64,20.29,
PROLONGED E/M +15MIN,8000103,CDM,983,RC,G2212,HCPCS,Outpatient,,,16.04,8.02,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.64,110,,,Fee Schedule,110% of Multiplan Fee Schedule,17.64,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,20.29,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.64,20.29,
LEVEL 1 EST PT,8000110,CDM,510,RC,99211,HCPCS,Outpatient,,,104.03,52.02,,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,70.74,68,,56.592,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,20.81,20,,16.648,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,67.62,65,,54.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,70.74,
IPPE VISIT,8000200,CDM,983,RC,G0402,HCPCS,Outpatient,,,243.6,121.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.12,110,,,Fee Schedule,110% of Multiplan Fee Schedule,143.12,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,164.59,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.12,164.59,
AWV INITIAL,8000201,CDM,983,RC,G0438,HCPCS,Outpatient,,,250.85,125.43,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,179.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,206.94,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.95,206.94,
AWV SUBSEQUENT,8000202,CDM,983,RC,G0439,HCPCS,Outpatient,,,169.65,84.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.23,110,,,Fee Schedule,110% of Multiplan Fee Schedule,141.23,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,,,,,Other,Not Seperately Reimbusable,162.41,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.23,162.41,
NEG PRESSURE WOUND THERAPY NPWT<50CM2,8000230,CDM,510,RC,97605,HCPCS,Outpatient,,,186.45,93.23,,121.19,65,,96.952,Percent of Total Billed Charges,65% of Total Billed Charges,126.79,68,,101.432,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.29,20,,29.832,Percent of Total Billed Charges,20% of Total Billed Charges,37.29,20,,29.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.29,20,,29.832,Percent of Total Billed Charges,20% of Total Billed Charges,37.29,20,,29.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.19,65,,96.952,Percent of Total Billed Charges,65% of Total Billed Charges,121.19,65,,96.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.29,126.79,
CHEMICAL CAUT GRAN TISSUE,8000272,CDM,983,RC,17250,HCPCS,Outpatient,,,141.11,70.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,41.48,110,,,Fee Schedule,110% of Multiplan Fee Schedule,41.48,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,47.7,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,77.32,100,,,Case Rate,Pays Based on per visit rate,24.72,100,,,Fee Schedule,100% of FL Medicaid Rate,24.72,100,,,Fee Schedule,100% of FL Medicaid rate,24.72,77.32,
DEBRID SUBC 1ST 20CM/LESS,8000274,CDM,983,RC,11042,HCPCS,Outpatient,,,211.15,105.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,66.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,66.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,76.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,93.21,100,,,Case Rate,Pays Based on per visit rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid rate,40.61,93.21,
DEBRID SUB ADDL 20 CM PROFEE,8000275,CDM,983,RC,11045,HCPCS,Outpatient,,,41.95,20.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,28.4,110,,,Fee Schedule,110% of Multiplan Fee Schedule,28.4,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,32.66,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.37,100,,,Case Rate,Pays Based on per visit rate,17.77,100,,,Fee Schedule,100% of FL Medicaid Rate,17.77,100,,,Fee Schedule,100% of FL Medicaid rate,17.77,70.37,
LEVEL 3 EST PAT PRO FEE,8000276,CDM,983,RC,99213,HCPCS,Outpatient,,,249.26,124.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,144.66,109,,,Fee Schedule,109% of Multiplan Fee Schedule,144.66,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,83.01,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,82.22,100,,,Case Rate,Pays Based on per visit rate,29.62,100,,,Fee Schedule,100% of FL Medicaid Rate,29.62,100,,,Fee Schedule,100% of FL Medicaid rate,29.62,144.66,
LEVEL 1 NEW PAT PRO FEE,8000277,CDM,983,RC,,,Outpatient,,,91.67,45.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LEVEL 2 EST PAT PRO FEE,8000278,CDM,983,RC,99212,HCPCS,Outpatient,,,88.58,44.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,77.93,109,,,Fee Schedule,109% of Multiplan Fee Schedule,77.93,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,44.62,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.08,100,,,Case Rate,Pays Based on per visit rate,17.48,100,,,Fee Schedule,100% of FL Medicaid Rate,17.48,100,,,Fee Schedule,100% of FL Medicaid rate,17.48,77.93,
LEVEL 2 NEW PAT PRO FEE,8000279,CDM,983,RC,99202,HCPCS,Outpatient,,,173.04,86.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,100,,,Fee Schedule,100% of FL Medicaid Rate,33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,100,,,Fee Schedule,100% of FL Medicaid Rate,33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,33,100,,,Fee Schedule,100% of FL Medicaid Rate,104.93,109,,,Fee Schedule,109% of Multiplan Fee Schedule,104.93,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,33,100,,,Fee Schedule,100% of FL Medicaid Rate,59.87,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,33,100,,,Fee Schedule,100% of FL Medicaid Rate,33,100,,,Fee Schedule,100% of FL Medicaid Rate,33,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,85.6,100,,,Case Rate,Pays Based on per visit rate,33,100,,,Fee Schedule,100% of FL Medicaid Rate,33,100,,,Fee Schedule,100% of FL Medicaid rate,33,104.93,
LEVEL 3 NEW PAT PRO FEE,8000280,CDM,983,RC,99203,HCPCS,Outpatient,,,258.53,129.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,182.3,109,,,Fee Schedule,109% of Multiplan Fee Schedule,182.3,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,104.06,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,103.83,100,,,Case Rate,Pays Based on per visit rate,51.23,100,,,Fee Schedule,100% of FL Medicaid Rate,51.23,100,,,Fee Schedule,100% of FL Medicaid rate,51.23,182.3,
LEVEL 4 EST PT PRO FEE,8000281,CDM,983,RC,99214,HCPCS,Outpatient,,,268.83,134.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,213.19,109,,,Fee Schedule,109% of Multiplan Fee Schedule,213.19,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,122.25,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,98.75,100,,,Case Rate,Pays Based on per visit rate,46.15,100,,,Fee Schedule,100% of FL Medicaid Rate,46.15,100,,,Fee Schedule,100% of FL Medicaid rate,46.15,213.19,
LEVEL 5 EST PAT PRO FEE,8000282,CDM,983,RC,99215,HCPCS,Outpatient,,,379.04,189.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,314.76,109,,,Fee Schedule,109% of Multiplan Fee Schedule,314.76,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,181.6,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,119.68,100,,,Case Rate,Pays Based on per visit rate,67.08,100,,,Fee Schedule,100% of FL Medicaid Rate,67.08,100,,,Fee Schedule,100% of FL Medicaid rate,67.08,314.76,
LEVEL 5 NEW PAT PRO FEE,8000283,CDM,983,RC,99205,HCPCS,Outpatient,,,576.8,288.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,399.09,109,,,Fee Schedule,109% of Multiplan Fee Schedule,399.09,109,,,Fee Schedule,109% of Multiplan Complimentary Network Fee Schedule,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,229.69,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,167.02,100,,,Case Rate,Pays Based on per visit rate,114.42,100,,,Fee Schedule,100% of FL Medicaid Rate,114.42,100,,,Fee Schedule,100% of FL Medicaid rate,114.42,399.09,
AVULSION NAILPLATE PART/COMP SIMP ADD,8000284,CDM,510,RC,11732,HCPCS,Outpatient,,,156.56,78.28,,101.76,65,,81.408,Percent of Total Billed Charges,65% of Total Billed Charges,106.46,68,,85.168,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.31,20,,25.048,Percent of Total Billed Charges,20% of Total Billed Charges,31.31,20,,25.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.31,20,,25.048,Percent of Total Billed Charges,20% of Total Billed Charges,31.31,20,,25.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.76,65,,81.408,Percent of Total Billed Charges,65% of Total Billed Charges,101.76,65,,81.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.31,178,
CHEMICAL CAUTERY TISSUE,8000285,CDM,510,RC,17250,HCPCS,Outpatient,,,309,154.50,,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,210.12,68,,168.096,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,61.8,20,,49.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,200.85,65,,160.68,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,210.12,
DEB SUBQ TISSUE ADD-ON,8000286,CDM,510,RC,11045,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,178,
DEB SUBQ TISSUE 20 SQ CM/<,8000287,CDM,510,RC,11042,HCPCS,Outpatient,,,396.55,198.28,,257.76,65,,206.208,Percent of Total Billed Charges,65% of Total Billed Charges,269.65,68,,215.72,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,79.31,20,,63.448,Percent of Total Billed Charges,20% of Total Billed Charges,79.31,20,,63.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.31,20,,63.448,Percent of Total Billed Charges,20% of Total Billed Charges,79.31,20,,63.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.76,65,,206.208,Percent of Total Billed Charges,65% of Total Billed Charges,257.76,65,,206.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,419,
DRAINAGE ABSCESS SIMPLE/SINGLE,8000288,CDM,510,RC,10060,HCPCS,Outpatient,,,372.86,186.43,,242.36,65,,193.888,Percent of Total Billed Charges,65% of Total Billed Charges,253.54,68,,202.832,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.57,20,,59.656,Percent of Total Billed Charges,20% of Total Billed Charges,74.57,20,,59.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.57,20,,59.656,Percent of Total Billed Charges,20% of Total Billed Charges,74.57,20,,59.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,242.36,65,,193.888,Percent of Total Billed Charges,65% of Total Billed Charges,242.36,65,,193.888,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,253.54,
I & D ABSCESS COMPLEX,8000289,CDM,510,RC,10061,HCPCS,Outpatient,,,592.25,296.13,,384.96,65,,307.968,Percent of Total Billed Charges,65% of Total Billed Charges,402.73,68,,322.184,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.45,20,,94.76,Percent of Total Billed Charges,20% of Total Billed Charges,118.45,20,,94.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.45,20,,94.76,Percent of Total Billed Charges,20% of Total Billed Charges,118.45,20,,94.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.96,65,,307.968,Percent of Total Billed Charges,65% of Total Billed Charges,384.96,65,,307.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,402.73,
I & D ABSCESS COMP/MULTI,8000290,CDM,983,RC,10061,HCPCS,Outpatient,,,674.65,337.33,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,202.74,110,,,Fee Schedule,110% of Multiplan Fee Schedule,202.74,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,233.15,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,176.89,100,,,Case Rate,Pays Based on per visit rate,124.29,100,,,Fee Schedule,100% of FL Medicaid Rate,124.29,100,,,Fee Schedule,100% of FL Medicaid rate,124.29,233.15,
I & D HEMATOMA SEROMA/FLUID,8000291,CDM,510,RC,10140,HCPCS,Outpatient,,,515,257.50,,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,350.2,68,,280.16,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,103,20,,82.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,334.75,65,,267.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,665,
I & D HEMATOMA FLUID PF,8000292,CDM,983,RC,10140,HCPCS,Outpatient,,,401.7,200.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,130.27,110,,,Fee Schedule,110% of Multiplan Fee Schedule,130.27,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,149.81,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,132.66,100,,,Case Rate,Pays Based on per visit rate,80.06,100,,,Fee Schedule,100% of FL Medicaid Rate,80.06,100,,,Fee Schedule,100% of FL Medicaid rate,80.06,149.81,
APPLY UNNA BOOT,8000293,CDM,510,RC,29580,HCPCS,Outpatient,,,164.8,82.40,,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,112.06,68,,89.648,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,32.96,20,,26.368,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,107.12,65,,85.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.96,178,
APPLY UNNA BOOT PRO FEE,8000294,CDM,983,RC,29580,HCPCS,Outpatient,,,107.12,53.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,29.36,110,,,Fee Schedule,110% of Multiplan Fee Schedule,29.36,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,33.76,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.55,100,,,Case Rate,Pays Based on per visit rate,17.95,100,,,Fee Schedule,100% of FL Medicaid Rate,17.95,100,,,Fee Schedule,100% of FL Medicaid rate,17.95,70.55,
DEBRID DEVITAL TIS 20 CM/< PRO FEE,8000295,CDM,983,RC,97597,HCPCS,Outpatient,,,180.25,90.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,38.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,38.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,44.79,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,70.72,100,,,Case Rate,Pays Based on per visit rate,18.12,100,,,Fee Schedule,100% of FL Medicaid Rate,18.12,100,,,Fee Schedule,100% of FL Medicaid rate,18.12,70.72,
DEBRID DEVITAL TIS 20 CM/<,8000296,CDM,510,RC,97597,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,178,
DEBRID ADD ON 20 CM/ <,8000297,CDM,510,RC,97598,HCPCS,Outpatient,,,155.53,77.77,,101.09,65,,80.872,Percent of Total Billed Charges,65% of Total Billed Charges,105.76,68,,84.608,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.11,20,,24.888,Percent of Total Billed Charges,20% of Total Billed Charges,31.11,20,,24.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.11,20,,24.888,Percent of Total Billed Charges,20% of Total Billed Charges,31.11,20,,24.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.09,65,,80.872,Percent of Total Billed Charges,65% of Total Billed Charges,101.09,65,,80.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.11,178,
DEBRIDE ADD ON 20 CM/<,8000298,CDM,983,RC,97598,HCPCS,Outpatient,,,90.64,45.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,27.35,110,,,Fee Schedule,110% of Multiplan Fee Schedule,27.35,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,31.45,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,61.11,100,,,Case Rate,Pays Based on per visit rate,8.51,100,,,Fee Schedule,100% of FL Medicaid Rate,8.51,100,,,Fee Schedule,100% of FL Medicaid rate,8.51,61.11,
DEB MUSCLE 20 SQ CM/<PROFEE,8000299,CDM,983,RC,11043,HCPCS,Outpatient,,,242.67,121.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,171.05,110,,,Fee Schedule,110% of Multiplan Fee Schedule,171.05,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,196.71,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,156.67,100,,,Case Rate,Pays Based on per visit rate,104.07,100,,,Fee Schedule,100% of FL Medicaid Rate,104.07,100,,,Fee Schedule,100% of FL Medicaid rate,104.07,196.71,
DEB MUSCLE 20 SQ CM/<,8000300,CDM,510,RC,11043,HCPCS,Outpatient,,,752.93,376.47,,489.4,65,,391.52,Percent of Total Billed Charges,65% of Total Billed Charges,511.99,68,,409.592,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,150.59,20,,120.472,Percent of Total Billed Charges,20% of Total Billed Charges,150.59,20,,120.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.59,20,,120.472,Percent of Total Billed Charges,20% of Total Billed Charges,150.59,20,,120.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,489.4,65,,391.52,Percent of Total Billed Charges,65% of Total Billed Charges,489.4,65,,391.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,511.99,
DEB MUSCLE ADD ON 20 SQ CM,8000301,CDM,510,RC,11046,HCPCS,Outpatient,,,257.5,128.75,,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,175.1,68,,140.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,51.5,20,,41.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,167.38,65,,133.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,178,
DEB MUSCLE ADD ON 20 SQ CM PROFEE,8000302,CDM,983,RC,11046,HCPCS,Outpatient,,,77.71,38.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,61.92,110,,,Fee Schedule,110% of Multiplan Fee Schedule,61.92,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,71.21,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,90.21,100,,,Case Rate,Pays Based on per visit rate,37.61,100,,,Fee Schedule,100% of FL Medicaid Rate,37.61,100,,,Fee Schedule,100% of FL Medicaid rate,37.61,90.21,
DEB BONE/MUSCLE 20 SQ CM/<PRO FEE,8000303,CDM,983,RC,11044,HCPCS,Outpatient,,,327.85,163.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,252.65,110,,,Fee Schedule,110% of Multiplan Fee Schedule,252.65,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,290.55,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,204.9,100,,,Case Rate,Pays Based on per visit rate,152.3,100,,,Fee Schedule,100% of FL Medicaid Rate,152.3,100,,,Fee Schedule,100% of FL Medicaid rate,152.3,290.55,
DEB BONE/MUSCLE 20 SQ CM/<,8000304,CDM,510,RC,11044,HCPCS,Outpatient,,,879.62,439.81,,571.75,65,,457.4,Percent of Total Billed Charges,65% of Total Billed Charges,598.14,68,,478.512,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,175.92,20,,140.736,Percent of Total Billed Charges,20% of Total Billed Charges,175.92,20,,140.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.92,20,,140.736,Percent of Total Billed Charges,20% of Total Billed Charges,175.92,20,,140.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,571.75,65,,457.4,Percent of Total Billed Charges,65% of Total Billed Charges,571.75,65,,457.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,598.14,
DEB BONE/MUSCLE ADD ON PROFEE,8000305,CDM,983,RC,11047,HCPCS,Outpatient,,,129.37,64.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,109.63,110,,,Fee Schedule,110% of Multiplan Fee Schedule,109.63,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,126.07,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,118.36,100,,,Case Rate,Pays Based on per visit rate,65.76,100,,,Fee Schedule,100% of FL Medicaid Rate,65.76,100,,,Fee Schedule,100% of FL Medicaid rate,65.76,126.07,
TANGNTL BX SKIN SING LESION,8000306,CDM,510,RC,11102,HCPCS,Outpatient,,,314.15,157.08,,204.2,65,,163.36,Percent of Total Billed Charges,65% of Total Billed Charges,213.62,68,,170.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,20,,50.264,Percent of Total Billed Charges,20% of Total Billed Charges,62.83,20,,50.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,20,,50.264,Percent of Total Billed Charges,20% of Total Billed Charges,62.83,20,,50.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.2,65,,163.36,Percent of Total Billed Charges,65% of Total Billed Charges,204.2,65,,163.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,213.62,
TANGNTL BX SKIN SINGL LESION PRO FEE,8000307,CDM,983,RC,11102,HCPCS,Outpatient,,,128.75,64.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,41.31,110,,,Fee Schedule,110% of Multiplan Fee Schedule,41.31,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,47.5,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,77.98,100,,,Case Rate,Pays Based on per visit rate,25.38,100,,,Fee Schedule,100% of FL Medicaid Rate,25.38,100,,,Fee Schedule,100% of FL Medicaid rate,25.38,77.98,
DEB BONE ADD-ON,8000308,CDM,510,RC,11047,HCPCS,Outpatient,,,430.54,215.27,,279.85,65,,223.88,Percent of Total Billed Charges,65% of Total Billed Charges,292.77,68,,234.216,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.11,20,,68.888,Percent of Total Billed Charges,20% of Total Billed Charges,86.11,20,,68.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.11,20,,68.888,Percent of Total Billed Charges,20% of Total Billed Charges,86.11,20,,68.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.85,65,,223.88,Percent of Total Billed Charges,65% of Total Billed Charges,279.85,65,,223.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,292.77,
CL AVULSION NAIL PLATE SIMPLE,8000309,CDM,510,RC,11730,HCPCS,Outpatient,,,207.03,103.52,,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,140.78,68,,112.624,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,41.41,20,,33.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,134.57,65,,107.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.41,178,
CL REMOVAL NAIL PLATE SIMPLE,8000310,CDM,983,RC,11730,HCPCS,Outpatient,,,180.25,90.13,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,59.06,110,,,Fee Schedule,110% of Multiplan Fee Schedule,59.06,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,67.92,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,88.82,100,,,Case Rate,Pays Based on per visit rate,36.22,100,,,Fee Schedule,100% of FL Medicaid Rate,36.22,100,,,Fee Schedule,100% of FL Medicaid rate,36.22,88.82,
INS/DRAIN THROMBOSED HEMORRHOID,8000311,CDM,510,RC,46083,HCPCS,Outpatient,,,414.06,207.03,,269.14,65,,215.312,Percent of Total Billed Charges,65% of Total Billed Charges,281.56,68,,225.248,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.81,20,,66.248,Percent of Total Billed Charges,20% of Total Billed Charges,82.81,20,,66.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.81,20,,66.248,Percent of Total Billed Charges,20% of Total Billed Charges,82.81,20,,66.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.14,65,,215.312,Percent of Total Billed Charges,65% of Total Billed Charges,269.14,65,,215.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,281.56,
INS/DRAIN THROMBOSED HEMORRHOID,8000312,CDM,983,RC,46083,HCPCS,Outpatient,,,360.5,180.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,122.85,110,,,Fee Schedule,110% of Multiplan Fee Schedule,122.85,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,141.28,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,127.52,100,,,Case Rate,Pays Based on per visit rate,74.92,100,,,Fee Schedule,100% of FL Medicaid Rate,74.92,100,,,Fee Schedule,100% of FL Medicaid rate,74.92,141.28,
EXCISION NAIL MATRIX PERM RMVL,8000313,CDM,510,RC,11750,HCPCS,Outpatient,,,333.72,166.86,,216.92,65,,173.536,Percent of Total Billed Charges,65% of Total Billed Charges,226.93,68,,181.544,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.74,20,,53.392,Percent of Total Billed Charges,20% of Total Billed Charges,66.74,20,,53.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.74,20,,53.392,Percent of Total Billed Charges,20% of Total Billed Charges,66.74,20,,53.392,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.92,65,,173.536,Percent of Total Billed Charges,65% of Total Billed Charges,216.92,65,,173.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,226.93,
EXCISION NAIL MATRIX PERM REMOVAL,8000314,CDM,983,RC,11750,HCPCS,Outpatient,,,210.12,105.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,111.22,110,,,Fee Schedule,110% of Multiplan Fee Schedule,111.22,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,127.9,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,121.13,100,,,Case Rate,Pays Based on per visit rate,68.53,100,,,Fee Schedule,100% of FL Medicaid Rate,68.53,100,,,Fee Schedule,100% of FL Medicaid rate,68.53,127.9,
EXC BENIGN LESION 1.1-2.0 CM,8000315,CDM,510,RC,11402,HCPCS,Outpatient,,,391.4,195.70,,254.41,65,,203.528,Percent of Total Billed Charges,65% of Total Billed Charges,266.15,68,,212.92,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.28,20,,62.624,Percent of Total Billed Charges,20% of Total Billed Charges,78.28,20,,62.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.28,20,,62.624,Percent of Total Billed Charges,20% of Total Billed Charges,78.28,20,,62.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254.41,65,,203.528,Percent of Total Billed Charges,65% of Total Billed Charges,254.41,65,,203.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,296,
EXC BENIGN LESION 1.1-2.0 CM PRO FEE,8000316,CDM,983,RC,11402,HCPCS,Outpatient,,,195.7,97.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,752,100,,,Fee Schedule,100% of Anesthesia,126.86,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,145.89,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,130.88,100,,,Case Rate,Pays Based on per visit rate,78.28,100,,,Fee Schedule,100% of FL Medicaid Rate,78.28,100,,,Fee Schedule,100% of FL Medicaid rate,78.28,752,
EXC BENIGN LESION TRUNK ARMS LEGS </.5CM,8000317,CDM,510,RC,11400,HCPCS,Outpatient,,,276.04,138.02,,179.43,65,,143.544,Percent of Total Billed Charges,65% of Total Billed Charges,187.71,68,,150.168,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.21,20,,44.168,Percent of Total Billed Charges,20% of Total Billed Charges,55.21,20,,44.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.21,20,,44.168,Percent of Total Billed Charges,20% of Total Billed Charges,55.21,20,,44.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.43,65,,143.544,Percent of Total Billed Charges,65% of Total Billed Charges,179.43,65,,143.544,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,296,
EXC BENIGN LESION T/A/L /<.5CM,8000318,CDM,983,RC,11400,HCPCS,Outpatient,,,113.3,56.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,91.98,110,,,Fee Schedule,110% of Multiplan Fee Schedule,91.98,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,105.78,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,108.37,100,,,Case Rate,Pays Based on per visit rate,55.77,100,,,Fee Schedule,100% of FL Medicaid Rate,55.77,100,,,Fee Schedule,100% of FL Medicaid rate,55.77,108.37,
DRAIN/INJ JOINT/BURSA W/O US,8000319,CDM,510,RC,20605,HCPCS,Outpatient,,,143.17,71.59,,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,97.36,68,,77.888,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,28.63,20,,22.904,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,93.06,65,,74.448,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.63,178,
DRAIN/INJ JOINT/BURSA W/O US,8000320,CDM,983,RC,20605,HCPCS,Outpatient,,,100.94,50.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,41.03,110,,,Fee Schedule,110% of Multiplan Fee Schedule,41.03,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,47.18,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,77.75,100,,,Case Rate,Pays Based on per visit rate,25.15,100,,,Fee Schedule,100% of FL Medicaid Rate,25.15,100,,,Fee Schedule,100% of FL Medicaid rate,25.15,77.75,
THORACENTESIS w/IMAGING,8000321,CDM,510,RC,32555,HCPCS,Outpatient,,,385.22,192.61,,250.39,65,,200.312,Percent of Total Billed Charges,65% of Total Billed Charges,261.95,68,,209.56,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,77.04,20,,61.632,Percent of Total Billed Charges,20% of Total Billed Charges,77.04,20,,61.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.04,20,,61.632,Percent of Total Billed Charges,20% of Total Billed Charges,77.04,20,,61.632,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.39,65,,200.312,Percent of Total Billed Charges,65% of Total Billed Charges,250.39,65,,200.312,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,419,
THORACENTESIS w/IMAGING PRO,8000322,CDM,983,RC,32555,HCPCS,Outpatient,,,195.7,97.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,119.24,110,,,Fee Schedule,110% of Multiplan Fee Schedule,119.24,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,137.13,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,126.66,100,,,Case Rate,Pays Based on per visit rate,74.06,100,,,Fee Schedule,100% of FL Medicaid Rate,74.06,100,,,Fee Schedule,100% of FL Medicaid rate,74.06,137.13,
TANGNTL BX SKIN EA SEP/ADDL,8000325,CDM,510,RC,11103,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,178,
PUNCH BX SKIN SINGLE LESION,8000326,CDM,510,RC,11104,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,178,
PUNCH BX SKIN EA SEP/ADDL,8000327,CDM,510,RC,11105,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,178,
REMOVE FOREIGN BODY,8000328,CDM,510,RC,10120,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,178,
TANGNTL BX SKIN EA SEP/ADDL PROFEE,8000329,CDM,983,RC,11103,HCPCS,Outpatient,,,195.7,97.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,23.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,23.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,27.54,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,67.37,100,,,Case Rate,Pays Based on per visit rate,14.77,100,,,Fee Schedule,100% of FL Medicaid Rate,14.77,100,,,Fee Schedule,100% of FL Medicaid rate,14.77,67.37,
PUNCH BX SKIN SINGLE LESION PROFEE,8000330,CDM,983,RC,11104,HCPCS,Outpatient,,,61.04,30.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,51.54,110,,,Fee Schedule,110% of Multiplan Fee Schedule,51.54,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,59.27,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,84.21,100,,,Case Rate,Pays Based on per visit rate,31.61,100,,,Fee Schedule,100% of FL Medicaid Rate,31.61,100,,,Fee Schedule,100% of FL Medicaid rate,31.61,84.21,
PUNCH BX ADDL,8000331,CDM,510,RC,11105,HCPCS,Outpatient,,,195.7,97.85,,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,133.08,68,,106.464,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,39.14,20,,31.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,127.21,65,,101.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.14,178,
PUNCH BX ADDL PROFEE,8000332,CDM,983,RC,11105,HCPCS,Outpatient,,,195.7,97.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,28.26,110,,,Fee Schedule,110% of Multiplan Fee Schedule,28.26,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,32.5,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,69.9,100,,,Case Rate,Pays Based on per visit rate,17.3,100,,,Fee Schedule,100% of FL Medicaid Rate,17.3,100,,,Fee Schedule,100% of FL Medicaid rate,17.3,69.9,
EXC TR-EXT MLG MARG 1.1-2 CM PROFEE,8000350,CDM,983,RC,11602,HCPCS,Outpatient,,,251.41,125.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,175.9,110,,,Fee Schedule,110% of Multiplan Fee Schedule,175.9,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,202.29,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,161.28,100,,,Case Rate,Pays Based on per visit rate,108.68,100,,,Fee Schedule,100% of FL Medicaid Rate,108.68,100,,,Fee Schedule,100% of FL Medicaid rate,108.68,202.29,
INJ. TENDON ORIGIN/INSERT PROFEE,8000351,CDM,983,RC,20551,HCPCS,Outpatient,,,59.83,29.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,42.91,110,,,Fee Schedule,110% of Multiplan Fee Schedule,42.91,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,49.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,79.14,100,,,Case Rate,Pays Based on per visit rate,26.54,100,,,Fee Schedule,100% of FL Medicaid Rate,26.54,100,,,Fee Schedule,100% of FL Medicaid rate,26.54,79.14,
SURGICAL PATHOLOGY LEVEL 4,8000825,CDM,310,RC,88305,HCPCS,Outpatient,,,150,75.00,,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,89,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,102,
"CULTURE, MICROORGANISMS",8000826,CDM,310,RC,88312,HCPCS,Outpatient,,,150,75.00,,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,102,
TISSUE LEVEL 3,8000827,CDM,310,RC,88304,HCPCS,Outpatient,,,150,75.00,,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,17,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,102,
SURGICAL PATHOLOGY LEVEL 2,8000828,CDM,310,RC,88302,HCPCS,Outpatient,,,150,75.00,,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,14,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,102,
LABEL-,8007310,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IM/SQ INJECTION-CLINIC,8011126,CDM,510,RC,96372,HCPCS,Outpatient,,,49.44,24.72,,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,33.62,68,,26.896,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,9.89,20,,7.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,32.14,65,,25.712,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,53.67,
ART/ASP/INJ SM JOINT,8031071,CDM,510,RC,20600,HCPCS,Outpatient,,,208.06,104.03,,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,141.48,68,,113.184,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,178,
ART/ASP/IN INT JOINT,8031073,CDM,510,RC,20605,HCPCS,Outpatient,,,208.06,104.03,,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,141.48,68,,113.184,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,41.61,20,,33.288,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,135.24,65,,108.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.61,178,
CLINIC FB SUBCUTANEOUS SIMP,8031087,CDM,510,RC,10120,HCPCS,Outpatient,,,410.12,205.06,,266.58,65,,213.264,Percent of Total Billed Charges,65% of Total Billed Charges,278.88,68,,223.104,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.02,20,,65.616,Percent of Total Billed Charges,20% of Total Billed Charges,82.02,20,,65.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.02,20,,65.616,Percent of Total Billed Charges,20% of Total Billed Charges,82.02,20,,65.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.58,65,,213.264,Percent of Total Billed Charges,65% of Total Billed Charges,266.58,65,,213.264,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,278.88,
CLINIC FB SUBCUTANEOUS SIMPPROFEE,8031088,CDM,983,RC,10120,HCPCS,Outpatient,,,210.12,105.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,115.28,110,,,Fee Schedule,110% of Multiplan Fee Schedule,115.28,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,132.57,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,122.75,100,,,Case Rate,Pays Based on per visit rate,70.15,100,,,Fee Schedule,100% of FL Medicaid Rate,70.15,100,,,Fee Schedule,100% of FL Medicaid rate,70.15,132.57,
SKIN SUB GRAFT T/A/L 25CM,8055512,CDM,360,RC,15271,HCPCS,Outpatient,,,1737,868.50,,1129.05,65,,903.24,Percent of Total Billed Charges,65% of Total Billed Charges,1181.16,68,,944.928,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,347.4,20,,277.92,Percent of Total Billed Charges,20% of Total Billed Charges,347.4,20,,277.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.4,20,,277.92,Percent of Total Billed Charges,20% of Total Billed Charges,347.4,20,,277.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1129.05,65,,903.24,Percent of Total Billed Charges,65% of Total Billed Charges,1129.05,65,,903.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1181.16,
GRAFIX PL PRIME (3X3),8055513,CDM,761,RC,Q4133,HCPCS,Outpatient,,,745,372.50,,484.25,65,,387.4,Percent of Total Billed Charges,65% of Total Billed Charges,506.6,68,,405.28,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149,20,,119.2,Percent of Total Billed Charges,20% of Total Billed Charges,149,20,,119.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149,20,,119.2,Percent of Total Billed Charges,20% of Total Billed Charges,149,20,,119.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,484.25,65,,387.4,Percent of Total Billed Charges,65% of Total Billed Charges,484.25,65,,387.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,506.6,
SKIN GRAFT T/A/L PRO FEE,8055514,CDM,983,RC,,,Outpatient,,,91.67,45.84,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLINIC DEBRIDEMENT-SUB 1ST 20CM OR LESS,8060402,CDM,510,RC,11042,HCPCS,Outpatient,,,721,360.50,,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,490.28,68,,392.224,Percent of Total Billed Charges,68% of Total Billed Charges,419,100,,,Fee Schedule,100% of ASC Tier Groupings,,,,,Other,Not Seperately Reimbusable,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,144.2,20,,115.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,468.65,65,,374.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,490.28,
CLINIC DEBRIDE-SUB 1ST 20CM PROFEE,8060403,CDM,983,RC,11042,HCPCS,Outpatient,,,86,43.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,66.95,110,,,Fee Schedule,110% of Multiplan Fee Schedule,66.95,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,76.99,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,93.21,100,,,Case Rate,Pays Based on per visit rate,40.61,100,,,Fee Schedule,100% of FL Medicaid Rate,40.61,100,,,Fee Schedule,100% of FL Medicaid rate,40.61,93.21,
APPLICATION SKIN SUB PROFEE,8060444,CDM,983,RC,15275,HCPCS,Outpatient,,,150,75.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,102.92,110,,,Fee Schedule,110% of Multiplan Fee Schedule,102.92,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,118.35,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,115.83,100,,,Case Rate,Pays Based on per visit rate,63.23,100,,,Fee Schedule,100% of FL Medicaid Rate,63.23,100,,,Fee Schedule,100% of FL Medicaid rate,63.23,118.35,
EKG PRIMARY CARE,8080001,CDM,983,RC,93000,HCPCS,Outpatient,,,357.41,178.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,15.54,110,,,Fee Schedule,110% of Multiplan Fee Schedule,15.54,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,17.87,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,62.68,100,,,Case Rate,Pays Based on per visit rate,10.08,100,,,Fee Schedule,100% of FL Medicaid Rate,10.08,100,,,Fee Schedule,100% of FL Medicaid rate,10.08,62.68,
PSYCHIATRIC DIAGNOSTIC EVALUATION,8200002,CDM,914,RC,90791,HCPCS,Outpatient,,,395.37,197.69,,256.99,65,,205.592,Percent of Total Billed Charges,65% of Total Billed Charges,268.85,68,,215.08,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.07,20,,63.256,Percent of Total Billed Charges,20% of Total Billed Charges,79.07,20,,63.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.07,20,,63.256,Percent of Total Billed Charges,20% of Total Billed Charges,79.07,20,,63.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.99,65,,205.592,Percent of Total Billed Charges,65% of Total Billed Charges,256.99,65,,205.592,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.69,50,,158.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.07,268.85,
PSYCHOTHERAPY (53 MIN OR MORE),8200005,CDM,972,RC,90837,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
AUDIO-ONLY PSYCHOTHERAPY(53 MIN OR MORE),8200011,CDM,972,RC,90837,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.6,52.6,
SUCTION CANNISTER 2000CC,9012028,CDM,360,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
POWER PORT 8FR INS,25000001,CDM,982,RC,36571,HCPCS,Outpatient,,,3893.25,1946.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,350.77,110,,,Fee Schedule,110% of Multiplan Fee Schedule,350.77,110,,,Fee Schedule,110% of Multiplan Complimentary Network Fee Schedule,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,403.38,126.5,,,Fee Schedule,126.50% of CMS OPPS Rate ,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,,,,,Other,Not Seperately Reimbusable,266.28,100,,,Case Rate,Pays Based on per visit rate,213.68,100,,,Fee Schedule,100% of FL Medicaid Rate,213.68,100,,,Fee Schedule,100% of FL Medicaid rate,213.68,403.38,
CATH/PORT DECLOTTING,31070103,CDM,761,RC,36593,HCPCS,Outpatient,,,85.49,42.75,,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,58.13,68,,46.504,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,17.1,20,,13.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,55.57,65,,44.456,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178,100,,,Fee Schedule,100% of ASC Tier Groupings,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,178,
ALPHA-GAL PANEL,40003100,CDM,301,RC,84439,HCPCS,Outpatient,,,91.67,45.84,,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,62.34,68,,49.872,Percent of Total Billed Charges,68% of Total Billed Charges,12.8,100,,,Fee Schedule,100% of BCBS Fee Schedule,,,,,Other,Not Seperately Reimbusable,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,18.33,20,,14.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,59.59,65,,47.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.84,50,,36.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,62.34,
EXPIRED/ DAMAGED DIETARY FOOD,41330070,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ECG TRUNK CABLE,80000122,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TABS CLEAR 1/3 CUT,80000228,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
POST-IT-POP UP,80000229,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TISSUE FACIAL 144/BX 3PK,80000287,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INFU-STAT PRESSURE BAG DISP. 1000ML,80000306,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOOTHETTES DISP,80000309,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ECG LEAD CABLE 7FT,80000330,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BINDER CLIP-SM,80000351,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PEN INK FINE POINT BLACK,80000408,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STORAGE BOX LETTER,80000416,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-THERMAL 3X1 (ADMT) LG,80000418,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-MEDICATION ADDED,80000419,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LETTER OPENER,80000420,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER 8.5 X 11 YELLOW,80000422,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER 8.5 X 11 PINK,80000423,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CHART FLAG YELLOW,80000570,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CHLORAPREP 10.5ML,80000833,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ADBOMINAL BELT FETAL,80001502,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLOROX VERSASURE WIPES,80001833,CDM,270,RC,,,Outpatient,,,51.22,25.61,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.24,20,,8.192,Percent of Total Billed Charges,20% of Total Billed Charges,10.24,20,,8.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.24,20,,8.192,Percent of Total Billed Charges,20% of Total Billed Charges,10.24,20,,8.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.29,65,,26.632,Percent of Total Billed Charges,65% of Total Billed Charges,33.29,65,,26.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.24,53.67,
NEEDLE 18G x 1.5,80005796,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENSURE PLUS-STRAWBERRY,80007308,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-DO NOT INTUBATE,80007310,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP 94/5740 BLACK,80010000,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP 95/5740 COLR,80010001,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP97 COLOR,80010003,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP98/5940 BLACK,80010004,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT KYO MITA FS3920DN BLK/MAG/CYAN/Y,80010005,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CART HP 61 TRI-COLOR/BLACK,80010006,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT KYO FSC5250DN LP-CYA,80010007,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT KYO FSC5250DN LP-YEL,80010008,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT KYO FSC5250DN LP-MAG,80010009,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT KYOCERA MITA TK592K BLACK,80010010,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CART KYOCERA TK352,80010011,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLINIC REGISTRATION BOOK,80010193,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
O R REGISTRATION BOOK,80010194,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLIP BOARD PLASTIC 9X13,80010196,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WIPES LCD & PLASMA SCREEN,80010197,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIVIDER W/ POCKET,80010198,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AVERY LABEL 8163,80010202,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HP CRT 910XL/910,80010204,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REINFORCEMENT LABELS,80010205,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HOLE PUNCH 2 HOLE H/D,80010206,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REFILL INK BLUE,80010207,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER- PINK THICK,80010210,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
2000+ REFILL INK PAD,80010211,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT 67XL BLK/COLOR,80010212,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FILE FOLDER HANGING 3  SUREHOOK,80010215,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EPSON REFILL 502 COLOR,80010216,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EPSON REFILL 502 BLACK,80010217,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HP REFILL 55A,80010218,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK REFILL HP 910 BCMY,80010219,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
POST IT FLAG 0.5,80010220,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HP 61XL/61 BLACK A& TRI COLOR INL CARTRI,80010225,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TONER TN-223BK,80010226,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIVIDERS 26-50,80010298,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIVIDERS 1-25,80010299,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIVIDERS ALPHABET A-Z,80010300,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIVIDERS TABS DAILY 1-31,80010301,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FOLDER 3 PRONG,80010302,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-CHART ID TAN,80010303,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FOLDER 2 POCKET,80010304,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RIBBON CALC NR-42/1212-2,80010305,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-THERMAL W/ NOTCH,80010333,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PENLIGHT DISPOSABLE 4.5in,80010334,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PUSH PINS,80010338,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
POST-IT SIGN HERE W/ ARROW,80010339,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BINDER CLIP-BLACK,80010340,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BINDER CLIP XL-BLACK 2 in,80010342,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EXPO DRY ERASE WIPES,80010343,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP 61 BLK CH561WN,80010344,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-NPO,80010345,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BATTERY AAA,80010346,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BATTERY AA,80010347,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BATTERY C,80010348,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BATTERY D,80010349,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RIBBON CALCULATOR BROTHERS TZe-231,80010350,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL AVERY 5351,80010351,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-AVERY 5160 (ADDRESS),80010352,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL AVERY 5630/CLEAR,80010353,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EXPO DRY ERASE CLEANER,80010354,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENVELOPES #10 WINDOW MCMH,80010357,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HP 910XL BLK,80010358,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-B.U.D,80010359,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SECURITY WINDOW ENV/ MCMH,80010360,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CORRECTION TAPE MONO,80010372,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIVIDER INDEX 8 TAB COLOR,80010375,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIVIDER INDEX 8 TAB CLEAR,80010376,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BINDER 1 IN,80010377,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EPSON RIBBON CARTRIDGE,80010380,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER 8.5 x 11 BLUE,80010386,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENVELOPES #10 PLAIN,80010389,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FILE FOLDER W/ FASTENER,80010390,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FILE FOLDER/LETTER MANILLA,80010391,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAPLES/STANDARD,80010392,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAPLER,80010393,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER BLACK,80010394,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE SCOTCH 3/4 IN TRANSPAR,80010395,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAMP-RCVD/ORIGINAL/MISC,80010396,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER SHARPIE RED CHISEL TIP,80010397,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BINDER 1.5 IN,80010398,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BINDER 2 IN,80010399,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER-YELLOW/THIN,80010400,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER-ORANGE/THIN,80010401,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
POST-IT-NOTES 3X3,80010402,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CORRECTION WHITEOUT LIQ,80010404,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PENCILS #2 W/ERASER,80010405,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ADDING PAPER ROLL 1/4X150,80010406,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INDEX CARDS 3X5,80010407,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT LEXMARK 16 BLACK,80010408,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAD PAPER 8.5 x11,80010409,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PEN RETRACTABLE BLK 1.0 MM,80010411,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER 8.5 X 14 WHITE,80010412,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BUTTERFLY CLAMPS (PAPER CLIPS),80010413,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER 8.5 X 11 WHITE,80010414,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STORAGE BOX SINGLE,80010415,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RED LOCK SAFETY CONTROL,80010416,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP78 CLR DJ930/920C,80010417,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP LASERJET 42A,80010418,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP LJ 600 M602 (CE390A),80010419,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL- BIOHAZARD 6.5X6.5,80010420,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL- BIOHAZARD CONTROL LABEL 2X3,80010421,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-DISCLOSURE CONSENT,80010422,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ELECTRONIC SURETEMP THERMOMETER W/A,80010423,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER 8.5 X 11 GREEN,80010424,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IV STABILIZATION/VENI-GARD,80010425,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLEARSITE 4X5 TRANSPARENT DRG,80010426,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLIP BOARD 8.5x11,80010427,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-THERMAL 3X1 (ADMT) SM,80010428,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-THERMAL GREEN PIGGYBACK,80010429,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FORM-SIGN IN LOG HIPPAA CMPLNT,80010430,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-NAME ALERT,80010431,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-RX DISCARD DATE,80010432,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-FENTANYL,80010433,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-HEPARIN,80010434,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-INSULIN,80010435,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-DOSAGE STRENGTH,80010436,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PEN INK MED POINT BLUE,80010437,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-MULTI-DOSE VIAL,80010438,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER SHARPIE RED REG PT,80010439,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WHITE FILE FOLDER LABELS 5005-0004-001,80010440,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PREVENTA PEN W/ CHAIN,80010441,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLEARSITE 2.5 x 2.8,80010442,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-THERMAL 3X2 PHARMACY,80010443,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EXPO DRY-ERASE ERASER,80010450,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER DRY ERASE MULTI COLOR PK,80010451,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER DRY ERASE SINGLE RED/BLUE,80010452,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FILE FOLDER PT OUTPATIENT,80010453,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER DRY ERASE BLACK,80010454,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER SHARPIE REG PT,80010455,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER SHARPIE BLACK U/F,80010456,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP 05A,80010457,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT OKIDATA B420DN,80010458,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP Q6511X,80010459,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP 15 BLK DJ 920C,80010460,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BINDER 2 IN,80010461,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT CANON CL245,80010462,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT CANON CL246,80010463,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK ROLLER REFILL/PORELON 42-2,80010464,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FOLDER HANGING FRAME/ LETTER,80010465,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER-PINK,80010466,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP 940XL MULTI REFILL,80010467,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP 940XL BLACK,80010468,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK ROLLER REFILL/ IR-40T,80010469,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT CANON PG240 XL,80010470,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIVIDER TAB JAN-DEC,80010471,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT CANON CL-241,80010472,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BINDER 3,80010473,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REGISTRATION BOOK ED (574B),80010474,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-CHART ALLERGIC,80010475,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP 26A,80010476,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER DRY ERASE BLUE,80010477,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER DRY ERASE GREEN,80010478,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MARKER DRY ERASE RED,80010479,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WALKER CARRY POUCH,80010480,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SCISSORS 8 IN METAL,80010482,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE BOX SEALING 2,80010483,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DYMO REFILL TAPE,80010484,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LAMINATE SHEET SELF-SEALNG,80010485,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER-YELLOW THICK,80010486,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER- MULTI-PCK-THICK,80010487,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ROLODEX CARD,80010490,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENVELOPE MAILER,80010491,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENVELOPE CLASP 9X12,80010492,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENVELOPE CLASP 10X13,80010493,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RUBBER BANDS #19 THIN,80010494,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RUBBER BANDS #64 THICK,80010495,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FASTNERS SELF ADHES 2 IN,80010496,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RX DESTROYER KIT,80010497,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER CLIP REGULAR,80010500,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER CLIP JUMBO,80010501,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER-GREEN THICK,80010506,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PEN INK FINE POINT RED,80010508,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ERASER PENCIL TOP,80010509,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE DICTATION MICRO,80010511,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE DISPENSER BLACK,80010519,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT CANON PG-275XL/276XL,80010520,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAD PAPER 5 x8',80010529,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-IV CHANGE MONDAY,80010542,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-IV CHANGE WEDNESDAY,80010544,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-IV CHANGE THURSDAY,80010545,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-IV CHANGE FRIDAY,80010546,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-IV CHANGE SATURDAY,80010547,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-IV CHANGE SUNDAY,80010548,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-CHART ID BLUE,80010550,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-CHART ID WHITE,80010551,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-CHART ID YELLOW,80010552,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-CHART ID GREEN,80010553,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-CHART ID ORANGE,80010554,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-D N R,80010555,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL- DO NOT THROW AWAY,80010556,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-FLAG YELLOW,80010570,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SORTKWIK FINGERTIP MOISTENER 1OZ,80010571,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAPLE REMOVER,80010572,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHEET PROTECTORS,80010573,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BATTERY 9V,80010585,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLIP BOARD 8.5x14,80010658,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FOLDER HANGING FILE LETTER,80010665,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FOLDER HANGING FILE LEGAL,80010666,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FOLDER HANGING LETTER/MUTLICOLOR,80010667,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER-GREEN,80010697,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIGHLIGHTER-BLUE/THIN,80010698,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAG-OUT OF SERVICE,80010773,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INK CRT HP45/51645A BLK,80010858,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BROTHER TN-820,80010859,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TONER CRT LEXMARK MS810 (521X),80010873,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TONER CRT LEXMARK MS331DN (THRIVE),80010874,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TONER CRT OKIDATA B420DN REFILL,80010875,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TONER CRT LEXMARK 55B1000,80010876,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL- RIBBON 4.33 MM,80012011,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENVELOPES #10 REG MCMH,80015358,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FORM-1500 INSURANCE 1PLY,80015417,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FORM-INVEN. (PT BELONGINGS),80015673,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FORM-UB-O4,80015729,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FORM DIETARY CHANGE SLIP,80015738,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-H&P NEEDED,80015822,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLUNT TIP NEEDLE 18X1,80015880,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EMERGENCY CRICOTHYROTOMY KIT,80015901,CDM,270,RC,,,Outpatient,,,504.68,252.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.94,20,,80.752,Percent of Total Billed Charges,20% of Total Billed Charges,100.94,20,,80.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.94,20,,80.752,Percent of Total Billed Charges,20% of Total Billed Charges,100.94,20,,80.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.04,65,,262.432,Percent of Total Billed Charges,65% of Total Billed Charges,328.04,65,,262.432,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,328.04,
MICROSTREAM CAPNOLINE W/O2,80020057,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MICROSTREAM SAMPLING LINE ADULT/PED'S,80020058,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SpO2 INFANT,80020126,CDM,270,RC,,,Outpatient,,,7.5,3.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.88,65,,3.904,Percent of Total Billed Charges,65% of Total Billed Charges,4.88,65,,3.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,53.67,
SILVER NITRATE STICKS,80020127,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BOOST BREEZE VARIETY CASE,80020128,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BOOST STRAWBERRY,80020129,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BOOST CHOCOLATE,80020130,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BOOST VANILLA,80020131,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE MEASURE/ RETRACTABLE,80020132,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLANKET BABY 32X32/ PINK & BLUE STRIPE,80020133,CDM,270,RC,,,Outpatient,,,4.61,2.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,20,,0.736,Percent of Total Billed Charges,20% of Total Billed Charges,0.92,20,,0.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,20,,0.736,Percent of Total Billed Charges,20% of Total Billed Charges,0.92,20,,0.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,65,,2.4,Percent of Total Billed Charges,65% of Total Billed Charges,3,65,,2.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,53.67,
CABLE NELLCOR spO2 EXTENDER CABLE,80020138,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SpO2 SENSOR DISPOSABLE ADULT,80020139,CDM,270,RC,,,Outpatient,,,7.5,3.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.88,65,,3.904,Percent of Total Billed Charges,65% of Total Billed Charges,4.88,65,,3.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,53.67,
BODY BAG 40x91 BLK ADULT,80020140,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SpO2 PEDIATRIC DISPSOSABLE,80020141,CDM,270,RC,,,Outpatient,,,7.5,3.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,1.5,20,,1.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.88,65,,3.904,Percent of Total Billed Charges,65% of Total Billed Charges,4.88,65,,3.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,53.67,
SpO2 RUBBER RE-USE,80020142,CDM,270,RC,,,Outpatient,,,88,44.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.2,65,,45.76,Percent of Total Billed Charges,65% of Total Billed Charges,57.2,65,,45.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,57.2,
SpO2 FOREHEAD,80020143,CDM,270,RC,,,Outpatient,,,24.92,12.46,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.98,20,,3.984,Percent of Total Billed Charges,20% of Total Billed Charges,4.98,20,,3.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.98,20,,3.984,Percent of Total Billed Charges,20% of Total Billed Charges,4.98,20,,3.984,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,65,,12.96,Percent of Total Billed Charges,65% of Total Billed Charges,16.2,65,,12.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.98,53.67,
SpO2 AD OXIMAX,80020144,CDM,270,RC,,,Outpatient,,,88,44.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.2,65,,45.76,Percent of Total Billed Charges,65% of Total Billed Charges,57.2,65,,45.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,57.2,
WIPE SKIN BARRIER PREP,80020151,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHOE COVERS SKID RESISTANT,80020170,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COBAN 1  COHESIVE BANDAGE,80020179,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WIPE ADHESIVE REMOVER,80020180,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COBAN 4,80020181,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COBAN 2  COHESIVE BANDAGE,80020182,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PACKING STRIP PLAIN 1/4 x15',80020183,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOMOMARK SCAR MARKER,80020184,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOMOMARK MOLE MARKER,80020185,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOMOMARK NIPPLE MARKER,80020186,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MAMMO WIPES BRACCO,80020187,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KNEE SUPPORT,80020190,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHAMPOO CAPS,80020198,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BED PAN,80020201,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BEDPAN FRACTURE,80020202,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AIR/CANNED,80020204,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HYDROGEN PEROXIDE 16OZ,80020205,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ALCOHOL 16OZ,80020206,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BANDAID SPOTS,80020207,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GAUZE 4X4 NON-STERILE,80020208,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TISSUE FACIAL,80020209,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COMB HAIR,80020210,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LIP BALM/ MOISTURIZER,80020213,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RAZOR DISP,80020215,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MASK SURGICAL,80020216,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GAUZE 2X2 NON STERILE,80020217,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE MEDIPORE 6IN,80020218,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAD ALCOHOL PREP 100ct,80020219,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LANCETS GREY 23 G 1.8MM,80020220,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRAUMA SHEARS,80020221,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE TRANSPORE 1 IN,80020222,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INFANT FORMULA NEWBORN 2OZ,80020223,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MANICURE STICK 4 1/2 IN,80020224,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-STAT,80020225,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 3CC LUER LOK,80020226,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF DISP ADULT SM,80020228,CDM,270,RC,,,Outpatient,,,1.47,0.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,20,,0.232,Percent of Total Billed Charges,20% of Total Billed Charges,0.29,20,,0.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,20,,0.232,Percent of Total Billed Charges,20% of Total Billed Charges,0.29,20,,0.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,65,,0.768,Percent of Total Billed Charges,65% of Total Billed Charges,0.96,65,,0.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,53.67,
W/A PROBE WELL KIT 4FT  ORAL,80020229,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THERM  PROBE COVER (W/A),80020230,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ELECTRODES ADULT 5/PK,80020231,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BASIN EMESIS,80020232,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HANGING FILE POCKET/ PLASTIC,80020234,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAD NAIL POLISH REMOVER,80020235,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE FILTER 18G X 1.5 (305201),80020240,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 18G x 1,80020241,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 21G x 1.5,80020242,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 23G x 1,80020243,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 25G X 1,80020244,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 22G x 1,80020245,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 25G x5/8,80020246,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 25Gx1.5,80020247,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ISOLATION GOWNS WALL UNIT,80020249,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NIBP HOSE 3.5FT,80020250,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CUP PORTION CONTROL,80020251,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CUP MEDICINE 1 OZ,80020252,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF DISP INFANT,80020255,CDM,270,RC,,,Outpatient,,,1.47,0.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,20,,0.232,Percent of Total Billed Charges,20% of Total Billed Charges,0.29,20,,0.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,20,,0.232,Percent of Total Billed Charges,20% of Total Billed Charges,0.29,20,,0.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,65,,0.768,Percent of Total Billed Charges,65% of Total Billed Charges,0.96,65,,0.768,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,53.67,
THERM  PROBE COVER RECTAL,80020256,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EMESIS BAGS,80020257,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NIBP HOSE 3.5FT,80020259,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAMP REFILL PAD BLUE/ RED,80020260,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ALCOHOL WIPES 70%,80020261,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
W/A PROBE WELL KIT 4FT  RECTAL,80020263,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLIPPER FINGERNAIL,80020264,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF REUSABLE INFANT,80020265,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPECULA EAR 2.75MM (52432),80020266,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPECULA EAR 4.25MM (52434-U),80020267,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF REUSABLE CHILD,80020268,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE MICROPORE 1 IN,80020269,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE MICROPORE 2IN,80020270,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE MICROFOAM 3X5.5,80020271,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 21G x 1,80020273,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
URINE DRAINAGE BAG HOLDER,80020274,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF REUSABLE ADULT,80020275,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF REUSABLE ADULT LG,80020276,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BABY CAP NEWBORN/INFANT,80020277,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
2oz TRANSL PORTION CUP PLASTIC,80020278,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHOE COVERS KNEE LENGTH,80020279,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SAFETY GLASSES,80020280,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIBICLENS SURGICAL SCRUB 4 OZ,80020281,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MASK EARLOOP,80020282,CDM,270,RC,,,Outpatient,,,56.23,28.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.25,20,,9,Percent of Total Billed Charges,20% of Total Billed Charges,11.25,20,,9,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.25,20,,9,Percent of Total Billed Charges,20% of Total Billed Charges,11.25,20,,9,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.55,65,,29.24,Percent of Total Billed Charges,65% of Total Billed Charges,36.55,65,,29.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.25,53.67,
SAFETY GOGGLE REFILL LENSE,80020283,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DISP ANEROID SPHYGMOMANOMETER/ ISOLATION,80020284,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE ELASTICON 3 IN,80020285,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BETADINE SOLUTION 8OZ BOTTLE,80020286,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HIBICLENS SURGICAL SCRUB 15ML,80020287,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ELECTRODES 10 PK,80020288,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CATHETER CONDOM MALE 35MM,80020293,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOURNIQUETS NON-LATEX,80020295,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE SALINE FLUSH .9% 5ML,80020299,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLUCERNA 1.5,80020300,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLUCERNA-STRAWBERRY,80020301,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLUCERNA-CHOCOLATE,80020302,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE SALINE FLUSH .9% 10ML,80020303,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENSURE PLUS-CHOCOLATE,80020304,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENSURE ORIGINAL-VANILLA,80020305,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLUCERNA-VANILLA,80020307,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THERM  PROBE COVER ORAL,80020308,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE VIAL ACCESS (303367),80020309,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CUP PLASTIC 7 OZ,80020310,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENSURE PLUS-VANILLA,80020311,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
JEVITY 1.5,80020312,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENSURE ORIGINAL-CHOCOLATE,80020313,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
JEVITY 1.2,80020314,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENSURE ORIGINAL-STRAWBERRY,80020315,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FLASH DRIVE USB 2.0 32 GB,80020316,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BIOFREEZE TOP,80020317,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BANATROL ORAL SUPPLEMENT,80020318,CDM,270,RC,,,Outpatient,,,1.11,0.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,20,,0.176,Percent of Total Billed Charges,20% of Total Billed Charges,0.22,20,,0.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,20,,0.176,Percent of Total Billed Charges,20% of Total Billed Charges,0.22,20,,0.176,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,65,,0.576,Percent of Total Billed Charges,65% of Total Billed Charges,0.72,65,,0.576,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,53.67,
CABLE- PATIENT 4 WIRE,80020331,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CABLE-ECG 5 WIRE PATIENT,80020332,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER TELEMETRY,80020333,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE MEASURE PAPER INFANT 36IN,80020337,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CUP DENTURE DISP,80020342,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PUNCH BIOPSY 4MM,80020343,CDM,270,RC,,,Outpatient,,,99.1,49.55,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.82,20,,15.856,Percent of Total Billed Charges,20% of Total Billed Charges,19.82,20,,15.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.82,20,,15.856,Percent of Total Billed Charges,20% of Total Billed Charges,19.82,20,,15.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.42,65,,51.536,Percent of Total Billed Charges,65% of Total Billed Charges,64.42,65,,51.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.82,64.42,
NEEDLE 30G x .5,80020344,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DENTURE ADHESIVE,80020345,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DENTURE CLEANER,80020346,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPONGE DRAIN 4X4 STERILE 2PK,80020361,CDM,270,RC,,,Outpatient,,,7.56,3.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.51,20,,1.208,Percent of Total Billed Charges,20% of Total Billed Charges,1.51,20,,1.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.51,20,,1.208,Percent of Total Billed Charges,20% of Total Billed Charges,1.51,20,,1.208,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.91,65,,3.928,Percent of Total Billed Charges,65% of Total Billed Charges,4.91,65,,3.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.51,53.67,
PAPER ZOLL MONITOR,80020364,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NAPKINS SANITARY/12CT,80020365,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TWEEZER SLANT TIP,80020366,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STOPCOCK 3-WAY,80020400,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BASIN WASH,80020401,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE P/F NITRILE XLG,80020406,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HOLE PUNCH,80020411,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE REFILLS FOR BOX CUTTERS,80020422,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BRIEFS (UNDERPANTS) PULL-UP XL,80020426,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VAGINAL SPEC DISP SMALL,80020428,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
UNDERPADS,80020429,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
URINAL,80020430,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 60CC CATH TIP,80020431,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VAGINAL SPEC DISP MED,80020432,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BANDAID 1 x3,80020433,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THERMOMETER DIGITAL/ORAL,80020434,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLD PACK INSTANT,80020435,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIAPERS INFANT NEWBORN/ SM/MD,80020436,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STOMA POUCH CLAMP,80020438,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIAPERS ADULT XLARGE,80020439,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 10 CC LUER LOK,80020440,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 20ML LUER LOK,80020441,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 60CC LUER LOK,80020442,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WASHCLOTHES XL ATTENDS POP-UP,80020444,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VAGINAL SPEC DISP LARGE,80020445,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THERMOMETER DIGITAL/RECTAL,80020446,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PenBlade #11 DISPOSABLE,80020449,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBING SUCTION CONNECTOR 100FT,80020450,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEOTECH LITTLE SUCKER,80020451,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-CHART ID PINK,80020463,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BAGS PATIENT BELONGINGS,80020500,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BABY BOTTLE NIPPLE,80020501,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BANDAID 3X3 PEDIACTRIC,80020520,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WRISTBAND ADMIT ID,80020521,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LAMP-WA 03400 2.5V ILLUM,80020533,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LAMP WA 06500 3.5 OPT,80020534,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LAMP-WA 03100 3.5V OTO,80020535,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LAMP-WA 03000 3.5V OPT,80020536,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LAMP-WA 7800 6V ENDO,80020537,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LAMP-WA 4900 3.5V WALL UNIT,80020538,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-IV CHANGE TUESDAY,80020543,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHARPS COLLECTOR 5 QUART,80020646,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BIO-GLO OPHTHALMIC AGENT,80020649,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE DUROPORE 3 IN CLOTH,80020678,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PenBlade #15 DISPOSABLE,80020688,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PILL CRUSHER POUCH,80020716,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE P/F NITRILE MED,80020717,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOWELETTE ANTISEPTIC BZK,80020719,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE P/F NITRILE SM,80020727,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IRRIG .9% SALINE 110 ML,80020730,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KN95 MASK DISP.,80020770,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
N95 MASK,80020771,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE P/F NITRILE LG,80020832,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HYPAFIX DRESSING RETENTION 2 x30'',80020870,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REMEDY OLIVAMINE ANTIFUNGAL CREAM 4OZ,80020871,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PRESCRIPTION PADS ED/PT CARE,80020886,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SOCKS-NON SKID XL,80020890,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SWABCAP NEEDLE FREE DISINFECTION,80020900,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CAP BOUFFANT BLUE,80020901,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 5CC/LUER LOK,80020902,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE TB 27G X 1/2-1ML,80020903,CDM,270,RC,,,Outpatient,,,47.17,23.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.43,20,,7.544,Percent of Total Billed Charges,20% of Total Billed Charges,9.43,20,,7.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.43,20,,7.544,Percent of Total Billed Charges,20% of Total Billed Charges,9.43,20,,7.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.66,65,,24.528,Percent of Total Billed Charges,65% of Total Billed Charges,30.66,65,,24.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.43,53.67,
SYRINGE INSULIN 29G X 1/2 - 1ML,80020905,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAPE MEDIPORE 4,80020907,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPLINT ORTHO GLASS 5IN X 15 FT,80020908,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPLINT ORTHO GLASS 3IN X 15FT,80020909,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPLINT WRIST 9  (SAM),80020910,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF DISP ADULT BLUE/REG,80020911,CDM,270,RC,,,Outpatient,,,1.39,0.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,65,,0.72,Percent of Total Billed Charges,65% of Total Billed Charges,0.9,65,,0.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,53.67,
WATER DISTILLED 1GAL,80020912,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WRISTBAND SNAP ALERT-YELLOW FALL RISK,80020913,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WRISTBAND ALERT-RED,80020914,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF LARGE ADULT LONG,80020915,CDM,270,RC,,,Outpatient,,,2.81,1.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,20,,0.448,Percent of Total Billed Charges,20% of Total Billed Charges,0.56,20,,0.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,20,,0.448,Percent of Total Billed Charges,20% of Total Billed Charges,0.56,20,,0.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,65,,1.464,Percent of Total Billed Charges,65% of Total Billed Charges,1.83,65,,1.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,53.67,
WOUND RULER,80020916,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DERMAL CURETTE 4MM,80020917,CDM,270,RC,,,Outpatient,,,188.67,94.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,20,,30.184,Percent of Total Billed Charges,20% of Total Billed Charges,37.73,20,,30.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,20,,30.184,Percent of Total Billed Charges,20% of Total Billed Charges,37.73,20,,30.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.64,65,,98.112,Percent of Total Billed Charges,65% of Total Billed Charges,122.64,65,,98.112,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,122.64,
WRISTBAND ALERT-GREEN,80020918,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WRISTBAND SNAP ALERT-PURPLE DNR,80020919,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF DISP CHILD,80020920,CDM,270,RC,,,Outpatient,,,1.39,0.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,65,,0.72,Percent of Total Billed Charges,65% of Total Billed Charges,0.9,65,,0.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,53.67,
TAPE MEDIPORE SHEETS 5 7/8 X 11,80020921,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BIO BAGS 9X6 BLUE,80020922,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP CUFF DISP ADULT LONG,80020923,CDM,270,RC,,,Outpatient,,,1.49,0.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,20,,0.24,Percent of Total Billed Charges,20% of Total Billed Charges,0.3,20,,0.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,20,,0.24,Percent of Total Billed Charges,20% of Total Billed Charges,0.3,20,,0.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,65,,0.776,Percent of Total Billed Charges,65% of Total Billed Charges,0.97,65,,0.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,53.67,
BP CUFF DISP LG AD,80020924,CDM,270,RC,,,Outpatient,,,1.96,0.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,20,,0.312,Percent of Total Billed Charges,20% of Total Billed Charges,0.39,20,,0.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,20,,0.312,Percent of Total Billed Charges,20% of Total Billed Charges,0.39,20,,0.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,65,,1.016,Percent of Total Billed Charges,65% of Total Billed Charges,1.27,65,,1.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,53.67,
PEGASSIST SM INSOLE,80020925,CDM,270,RC,,,Outpatient,,,133.16,66.58,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.63,20,,21.304,Percent of Total Billed Charges,20% of Total Billed Charges,26.63,20,,21.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.63,20,,21.304,Percent of Total Billed Charges,20% of Total Billed Charges,26.63,20,,21.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.55,65,,69.24,Percent of Total Billed Charges,65% of Total Billed Charges,86.55,65,,69.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.63,86.55,
PEGASSIST MD INSOLE,80020926,CDM,270,RC,,,Outpatient,,,115.94,57.97,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.19,20,,18.552,Percent of Total Billed Charges,20% of Total Billed Charges,23.19,20,,18.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.19,20,,18.552,Percent of Total Billed Charges,20% of Total Billed Charges,23.19,20,,18.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.36,65,,60.288,Percent of Total Billed Charges,65% of Total Billed Charges,75.36,65,,60.288,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.19,75.36,
PEGASSIST LG INSOLE,80020927,CDM,270,RC,,,Outpatient,,,102.63,51.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.53,20,,16.424,Percent of Total Billed Charges,20% of Total Billed Charges,20.53,20,,16.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.53,20,,16.424,Percent of Total Billed Charges,20% of Total Billed Charges,20.53,20,,16.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.71,65,,53.368,Percent of Total Billed Charges,65% of Total Billed Charges,66.71,65,,53.368,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.53,66.71,
POST OP SHOE SM,80020928,CDM,270,RC,,,Outpatient,,,82.83,41.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.57,20,,13.256,Percent of Total Billed Charges,20% of Total Billed Charges,16.57,20,,13.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.57,20,,13.256,Percent of Total Billed Charges,20% of Total Billed Charges,16.57,20,,13.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.84,65,,43.072,Percent of Total Billed Charges,65% of Total Billed Charges,53.84,65,,43.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.57,53.84,
POST OP SHOE MD,80020929,CDM,270,RC,,,Outpatient,,,86.76,43.38,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.35,20,,13.88,Percent of Total Billed Charges,20% of Total Billed Charges,17.35,20,,13.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.35,20,,13.88,Percent of Total Billed Charges,20% of Total Billed Charges,17.35,20,,13.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.39,65,,45.112,Percent of Total Billed Charges,65% of Total Billed Charges,56.39,65,,45.112,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.35,56.39,
POST OP SHOE LG,80020930,CDM,270,RC,,,Outpatient,,,94.16,47.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.83,20,,15.064,Percent of Total Billed Charges,20% of Total Billed Charges,18.83,20,,15.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.83,20,,15.064,Percent of Total Billed Charges,20% of Total Billed Charges,18.83,20,,15.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.2,65,,48.96,Percent of Total Billed Charges,65% of Total Billed Charges,61.2,65,,48.96,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.83,61.2,
BRACE STRETCH BOOT SM,80020931,CDM,270,RC,,,Outpatient,,,31.95,15.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,6.39,20,,5.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.77,65,,16.616,Percent of Total Billed Charges,65% of Total Billed Charges,20.77,65,,16.616,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,53.67,
OB/GYN SWABSTICK 8in,80032054,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CATHETER CONDOM MALE 30MM,80032094,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SKIN BARRIER UROSTOMY 1,80032112,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STOCKINETTE 3 IN X 25 YD,80032126,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STOCKINETTE 6 IN X 25YD,80032128,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HEAT PACK INSTANT,80032192,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPANDAGE LG- HEAD SHLDTHI,80032204,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SUTURE 424H,80032324,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DECLOGGER YELLOW G or J TUBE 16-18 FR,80032346,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DECLOGGER GREEN G or J TUBE 20-22 FR,80032348,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EAR WICKS STERILE,80032384,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EAR CURETTE LOOP PURPLE,80032386,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EAR CURETTE LOOP GREEN,80032387,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EAR CURETTE LOOP BLUE,80032388,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EYE WASH REFILL 16 OZ,80032404,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THORA-SEAL III COLLECTION CHAMBER,80032419,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VALVE LOPEZ FEEDING,80032442,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 1ML LUER LOCK,80032458,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ESTEEM SURGICAL GLOVE 8.5,80032459,CDM,272,RC,,,Outpatient,,,1.38,0.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,0.28,20,,0.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,65,,0.72,Percent of Total Billed Charges,65% of Total Billed Charges,0.9,65,,0.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,53.67,
SUCTION TUBING STERILE 1/4X12,80032490,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEGADERM 2.5 x3,80032497,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEGADERM 8X12,80032498,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IV SET WITH CONTROL-A-FLOW 92 IN,80032570,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IV CONTROL-A-FLO AND EXT SET,80032572,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IV EXT SET 6IN MINIBORE,80032578,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PEDI PADS II ELECTRODES,80032588,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
3-WAY CATH 16FR 30 BLADDER,80032590,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HAND SANITIZER 67oz,80032601,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEGADERM 4X4,80032628,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
UREA CREAM,80032629,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WASHCLOTHES DRY 13X13.5,80032630,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NG-STRIP TUBE FASTNER,80032631,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IRRIG. 0.9% (SALJET),80032639,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MASK PROCEDURE W/ VISOR,80032660,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IV VIAL-MATE ADAPTOR,80032671,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IV DUAL LUER LOCK CAP,80032672,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
O2 DS SENSOR CLIP=ON,80032674,CDM,270,RC,,,Outpatient,,,88,44.00,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,17.6,20,,14.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.2,65,,45.76,Percent of Total Billed Charges,65% of Total Billed Charges,57.2,65,,45.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,57.2,
PRIMARY ADMIN SET 60 DROP 103,80032699,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IV- BURETROL SOL SET,80035872,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONNECTOR MAXPLUS TRU-SWAB,80035886,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HAND SANITIZER 8OZ PUMP,80035926,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LL INSULIN SYRINGE 1ML,80035934,CDM,270,RC,,,Outpatient,,,78.73,39.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.75,20,,12.6,Percent of Total Billed Charges,20% of Total Billed Charges,15.75,20,,12.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.75,20,,12.6,Percent of Total Billed Charges,20% of Total Billed Charges,15.75,20,,12.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.17,65,,40.936,Percent of Total Billed Charges,65% of Total Billed Charges,51.17,65,,40.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.75,53.67,
TROCAR (CHEST TUBE) 16FR X10,80035935,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TROCAR (CHEST TUBE) 32FR X 16,80035936,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TROCAR (CHEST TUBE) 28FR X16,80035937,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SANI WIPES RED,80035947,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MONOJECT SMARTIP,80035948,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EYE WASH 4oz,80035949,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ALL-IN ADULT IV ARMBOARD,80035950,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 50ml CATH TIP,80035982,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE 50ml LUER-LOK,80035983,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LIQUI-LOC PLUS SOLIDIFIER PK 1500,80040033,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VAPOR DIALATOR CLIPS,80050027,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RFA NEEDLE CANULA,80050028,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RFA 150MM CANULA,80050029,CDM,270,RC,,,Outpatient,,,662.12,331.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.42,20,,105.936,Percent of Total Billed Charges,20% of Total Billed Charges,132.42,20,,105.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.42,20,,105.936,Percent of Total Billed Charges,20% of Total Billed Charges,132.42,20,,105.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,430.38,65,,344.304,Percent of Total Billed Charges,65% of Total Billed Charges,430.38,65,,344.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,430.38,
TOURNIQUET 18x1 250/BX,80050194,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IV LL POLE CAPS,80050672,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DISPOSABLE FACE SHIELD,80062251,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE SURGICAL SIZE 7 1/2,80062268,CDM,272,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE SURGICAL SIZE 7,80062269,CDM,272,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GOWN STERILE SURGICAL ECLIPSE,80062270,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE 18X1.5,80062796,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE SURGICAL SIZE 6,80062799,CDM,272,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVES SURGICAL SIZE 6.5,80062800,CDM,272,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL-THERMAL 3.5X15X16  LAB,90000417,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SUTURE W24,90015842,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SUTURE D8552,90015844,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CRUTCHES ALUMINUM,90020137,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SURGICAL TOWELS/ GREEN,90020239,CDM,270,RC,,,Outpatient,,,35.02,17.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.76,65,,18.208,Percent of Total Billed Charges,65% of Total Billed Charges,22.76,65,,18.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,53.67,
MINOR DRAPE FEN 6X6,90032032,CDM,272,RC,,,Outpatient,,,37.54,18.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,20,,6.008,Percent of Total Billed Charges,20% of Total Billed Charges,7.51,20,,6.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,20,,6.008,Percent of Total Billed Charges,20% of Total Billed Charges,7.51,20,,6.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.4,65,,19.52,Percent of Total Billed Charges,65% of Total Billed Charges,24.4,65,,19.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,53.67,
QUIKCLOT EMS 4X4,90032310,CDM,272,RC,,,Outpatient,,,78.9,39.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.78,20,,12.624,Percent of Total Billed Charges,20% of Total Billed Charges,15.78,20,,12.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.78,20,,12.624,Percent of Total Billed Charges,20% of Total Billed Charges,15.78,20,,12.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.29,65,,41.032,Percent of Total Billed Charges,65% of Total Billed Charges,51.29,65,,41.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.78,53.67,
QUIKCLOT 3X4 ROLL,90032311,CDM,272,RC,,,Outpatient,,,78.9,39.45,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.78,20,,12.624,Percent of Total Billed Charges,20% of Total Billed Charges,15.78,20,,12.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.78,20,,12.624,Percent of Total Billed Charges,20% of Total Billed Charges,15.78,20,,12.624,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.29,65,,41.032,Percent of Total Billed Charges,65% of Total Billed Charges,51.29,65,,41.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.78,53.67,
PUREWICK FEMALE CATH,90032376,CDM,272,RC,,,Outpatient,,,45.42,22.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.08,20,,7.264,Percent of Total Billed Charges,20% of Total Billed Charges,9.08,20,,7.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.08,20,,7.264,Percent of Total Billed Charges,20% of Total Billed Charges,9.08,20,,7.264,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.52,65,,23.616,Percent of Total Billed Charges,65% of Total Billed Charges,29.52,65,,23.616,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.08,53.67,
STOOL MGMT SYSTEM-DIGNISHIELD,90032502,CDM,272,RC,,,Outpatient,,,623.02,311.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.6,20,,99.68,Percent of Total Billed Charges,20% of Total Billed Charges,124.6,20,,99.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.6,20,,99.68,Percent of Total Billed Charges,20% of Total Billed Charges,124.6,20,,99.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,404.96,65,,323.968,Percent of Total Billed Charges,65% of Total Billed Charges,404.96,65,,323.968,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,404.96,
STOOL MGMT COLLECTION BAGS-DIGNISHIELD,90032504,CDM,271,RC,,,Outpatient,,,87.19,43.60,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.44,20,,13.952,Percent of Total Billed Charges,20% of Total Billed Charges,17.44,20,,13.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.44,20,,13.952,Percent of Total Billed Charges,20% of Total Billed Charges,17.44,20,,13.952,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.67,65,,45.336,Percent of Total Billed Charges,65% of Total Billed Charges,56.67,65,,45.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.44,56.67,
N95 RESPIRATOR VFLEX 9105,90032532,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIANEAL 2000ML,90032569,CDM,272,RC,,,Outpatient,,,224.23,112.12,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.85,20,,35.88,Percent of Total Billed Charges,20% of Total Billed Charges,44.85,20,,35.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.85,20,,35.88,Percent of Total Billed Charges,20% of Total Billed Charges,44.85,20,,35.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.75,65,,116.6,Percent of Total Billed Charges,65% of Total Billed Charges,145.75,65,,116.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.85,145.75,
XEROFORM GAUZE 4x4,90032627,CDM,272,RC,,,Outpatient,,,5,2.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,53.67,
CONTAINER EMPTY EVACUATED,90032641,CDM,271,RC,,,Outpatient,,,13.91,6.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,20,,2.224,Percent of Total Billed Charges,20% of Total Billed Charges,2.78,20,,2.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,20,,2.224,Percent of Total Billed Charges,20% of Total Billed Charges,2.78,20,,2.224,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.04,65,,7.232,Percent of Total Billed Charges,65% of Total Billed Charges,9.04,65,,7.232,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,53.67,
PRISMA MATRIX 4-1/3 HEXAGON STERILE,90035938,CDM,272,RC,,,Outpatient,,,76.5,38.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,20,,12.24,Percent of Total Billed Charges,20% of Total Billed Charges,15.3,20,,12.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,20,,12.24,Percent of Total Billed Charges,20% of Total Billed Charges,15.3,20,,12.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.73,65,,39.784,Percent of Total Billed Charges,65% of Total Billed Charges,49.73,65,,39.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,53.67,
COBAN2,90035940,CDM,272,RC,,,Outpatient,,,167.18,83.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.44,20,,26.752,Percent of Total Billed Charges,20% of Total Billed Charges,33.44,20,,26.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.44,20,,26.752,Percent of Total Billed Charges,20% of Total Billed Charges,33.44,20,,26.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.67,65,,86.936,Percent of Total Billed Charges,65% of Total Billed Charges,108.67,65,,86.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.44,108.67,
COBAN2 LITE,90035941,CDM,271,RC,,,Outpatient,,,118.4,59.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.68,20,,18.944,Percent of Total Billed Charges,20% of Total Billed Charges,23.68,20,,18.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.68,20,,18.944,Percent of Total Billed Charges,20% of Total Billed Charges,23.68,20,,18.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.96,65,,61.568,Percent of Total Billed Charges,65% of Total Billed Charges,76.96,65,,61.568,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.68,76.96,
HYDROFERA BLUE 4x5,90035942,CDM,272,RC,,,Outpatient,,,123.72,61.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.74,20,,19.792,Percent of Total Billed Charges,20% of Total Billed Charges,24.74,20,,19.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.74,20,,19.792,Percent of Total Billed Charges,20% of Total Billed Charges,24.74,20,,19.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.42,65,,64.336,Percent of Total Billed Charges,65% of Total Billed Charges,80.42,65,,64.336,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.74,80.42,
ANASEPT WOUND CLEANSER,90035943,CDM,271,RC,,,Outpatient,,,105.48,52.74,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,20,,16.88,Percent of Total Billed Charges,20% of Total Billed Charges,21.1,20,,16.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,20,,16.88,Percent of Total Billed Charges,20% of Total Billed Charges,21.1,20,,16.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.56,65,,54.848,Percent of Total Billed Charges,65% of Total Billed Charges,68.56,65,,54.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,68.56,
HYDROFERA BLUE 6X6,90035944,CDM,272,RC,,,Outpatient,,,113.63,56.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.73,20,,18.184,Percent of Total Billed Charges,20% of Total Billed Charges,22.73,20,,18.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.73,20,,18.184,Percent of Total Billed Charges,20% of Total Billed Charges,22.73,20,,18.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.86,65,,59.088,Percent of Total Billed Charges,65% of Total Billed Charges,73.86,65,,59.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.73,73.86,
DRAWTEX 2X2,90035945,CDM,272,RC,,,Outpatient,,,48.64,24.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.73,20,,7.784,Percent of Total Billed Charges,20% of Total Billed Charges,9.73,20,,7.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.73,20,,7.784,Percent of Total Billed Charges,20% of Total Billed Charges,9.73,20,,7.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.62,65,,25.296,Percent of Total Billed Charges,65% of Total Billed Charges,31.62,65,,25.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.73,53.67,
VASECTOMY UNDERWEAR MD,90035946,CDM,272,RC,,,Outpatient,,,214.5,107.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.9,20,,34.32,Percent of Total Billed Charges,20% of Total Billed Charges,42.9,20,,34.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.9,20,,34.32,Percent of Total Billed Charges,20% of Total Billed Charges,42.9,20,,34.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.43,65,,111.544,Percent of Total Billed Charges,65% of Total Billed Charges,139.43,65,,111.544,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.9,139.43,
CAVILON ANTISEPTIC SPRAY,90035947,CDM,271,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CAVILON FOOT EMOLLIANT,90035948,CDM,271,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CAVILON SKIN PROTECTANT,90035949,CDM,271,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
Z STAT AEROCHAMBER,90040012,CDM,270,RC,,,Outpatient,,,69.34,34.67,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.87,20,,11.096,Percent of Total Billed Charges,20% of Total Billed Charges,13.87,20,,11.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.87,20,,11.096,Percent of Total Billed Charges,20% of Total Billed Charges,13.87,20,,11.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.07,65,,36.056,Percent of Total Billed Charges,65% of Total Billed Charges,45.07,65,,36.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.87,53.67,
Z STAT W/ MASK,90040013,CDM,270,RC,,,Outpatient,,,226.03,113.02,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.21,20,,36.168,Percent of Total Billed Charges,20% of Total Billed Charges,45.21,20,,36.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.21,20,,36.168,Percent of Total Billed Charges,20% of Total Billed Charges,45.21,20,,36.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.92,65,,117.536,Percent of Total Billed Charges,65% of Total Billed Charges,146.92,65,,117.536,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.21,146.92,
STYLET CoPILOT RIGID,90040046,CDM,272,RC,,,Outpatient,,,181.02,90.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.2,20,,28.96,Percent of Total Billed Charges,20% of Total Billed Charges,36.2,20,,28.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.2,20,,28.96,Percent of Total Billed Charges,20% of Total Billed Charges,36.2,20,,28.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.66,65,,94.128,Percent of Total Billed Charges,65% of Total Billed Charges,117.66,65,,94.128,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.2,117.66,
TRACHEOSTOMY SZ 4,90040048,CDM,272,RC,,,Outpatient,,,330.06,165.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.01,20,,52.808,Percent of Total Billed Charges,20% of Total Billed Charges,66.01,20,,52.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.01,20,,52.808,Percent of Total Billed Charges,20% of Total Billed Charges,66.01,20,,52.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.54,65,,171.632,Percent of Total Billed Charges,65% of Total Billed Charges,214.54,65,,171.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,214.54,
TRACHEOSTOMY SZ 6,90040049,CDM,272,RC,,,Outpatient,,,330.06,165.03,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.01,20,,52.808,Percent of Total Billed Charges,20% of Total Billed Charges,66.01,20,,52.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.01,20,,52.808,Percent of Total Billed Charges,20% of Total Billed Charges,66.01,20,,52.808,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.54,65,,171.632,Percent of Total Billed Charges,65% of Total Billed Charges,214.54,65,,171.632,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,214.54,
CANNULA NASAL HF,90040053,CDM,270,RC,,,Outpatient,,,68.08,34.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.25,65,,35.4,Percent of Total Billed Charges,65% of Total Billed Charges,44.25,65,,35.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,53.67,
HI-FLOW BUBBLE BOTTLE,90040054,CDM,270,RC,,,Outpatient,,,92.19,46.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.44,20,,14.752,Percent of Total Billed Charges,20% of Total Billed Charges,18.44,20,,14.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.44,20,,14.752,Percent of Total Billed Charges,20% of Total Billed Charges,18.44,20,,14.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.92,65,,47.936,Percent of Total Billed Charges,65% of Total Billed Charges,59.92,65,,47.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.44,59.92,
TRAP INLINE WATER TRAP,90040055,CDM,270,RC,,,Outpatient,,,53.28,26.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.66,20,,8.528,Percent of Total Billed Charges,20% of Total Billed Charges,10.66,20,,8.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.66,20,,8.528,Percent of Total Billed Charges,20% of Total Billed Charges,10.66,20,,8.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.63,65,,27.704,Percent of Total Billed Charges,65% of Total Billed Charges,34.63,65,,27.704,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.66,53.67,
CANNULA W/HEADGEAR MD,90040056,CDM,270,RC,,,Outpatient,,,279.8,139.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.96,20,,44.768,Percent of Total Billed Charges,20% of Total Billed Charges,55.96,20,,44.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.96,20,,44.768,Percent of Total Billed Charges,20% of Total Billed Charges,55.96,20,,44.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.87,65,,145.496,Percent of Total Billed Charges,65% of Total Billed Charges,181.87,65,,145.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,181.87,
CANNULA W/HEADGEAR LG,90040057,CDM,270,RC,,,Outpatient,,,279.8,139.90,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.96,20,,44.768,Percent of Total Billed Charges,20% of Total Billed Charges,55.96,20,,44.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.96,20,,44.768,Percent of Total Billed Charges,20% of Total Billed Charges,55.96,20,,44.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.87,65,,145.496,Percent of Total Billed Charges,65% of Total Billed Charges,181.87,65,,145.496,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,181.87,
CIRCUIT HEATED BiPap,90040058,CDM,270,RC,,,Outpatient,,,352.98,176.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.6,20,,56.48,Percent of Total Billed Charges,20% of Total Billed Charges,70.6,20,,56.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.6,20,,56.48,Percent of Total Billed Charges,20% of Total Billed Charges,70.6,20,,56.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.44,65,,183.552,Percent of Total Billed Charges,65% of Total Billed Charges,229.44,65,,183.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,229.44,
"TRAP, ARGYLE SPECIMAN TRAP",90040059,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WATER STERILE BAG 1000ML,90040060,CDM,272,RC,,,Outpatient,,,35.23,17.62,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.05,20,,5.64,Percent of Total Billed Charges,20% of Total Billed Charges,7.05,20,,5.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.05,20,,5.64,Percent of Total Billed Charges,20% of Total Billed Charges,7.05,20,,5.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.9,65,,18.32,Percent of Total Billed Charges,65% of Total Billed Charges,22.9,65,,18.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.05,53.67,
OPEN,90040061,CDM,270,RC,,,Outpatient,,,352.98,176.49,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.6,20,,56.48,Percent of Total Billed Charges,20% of Total Billed Charges,70.6,20,,56.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.6,20,,56.48,Percent of Total Billed Charges,20% of Total Billed Charges,70.6,20,,56.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.44,65,,183.552,Percent of Total Billed Charges,65% of Total Billed Charges,229.44,65,,183.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,229.44,
VAPOTHERM ADULT CANNULA,90040064,CDM,270,RC,,,Outpatient,,,268.93,134.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.79,20,,43.032,Percent of Total Billed Charges,20% of Total Billed Charges,53.79,20,,43.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.79,20,,43.032,Percent of Total Billed Charges,20% of Total Billed Charges,53.79,20,,43.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.8,65,,139.84,Percent of Total Billed Charges,65% of Total Billed Charges,174.8,65,,139.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,174.8,
HUMIDIFIER HI-LOW,90040065,CDM,270,RC,,,Outpatient,,,92.19,46.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.44,20,,14.752,Percent of Total Billed Charges,20% of Total Billed Charges,18.44,20,,14.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.44,20,,14.752,Percent of Total Billed Charges,20% of Total Billed Charges,18.44,20,,14.752,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.92,65,,47.936,Percent of Total Billed Charges,65% of Total Billed Charges,59.92,65,,47.936,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.44,59.92,
STAPLER W/ COUNTER SURGICAL,90062249,CDM,272,RC,,,Outpatient,,,65.28,32.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.06,20,,10.448,Percent of Total Billed Charges,20% of Total Billed Charges,13.06,20,,10.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.06,20,,10.448,Percent of Total Billed Charges,20% of Total Billed Charges,13.06,20,,10.448,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.43,65,,33.944,Percent of Total Billed Charges,65% of Total Billed Charges,42.43,65,,33.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.06,53.67,
SPONGE LAP XRAY 18X18,90062250,CDM,272,RC,,,Outpatient,,,19.73,9.87,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.95,20,,3.16,Percent of Total Billed Charges,20% of Total Billed Charges,3.95,20,,3.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.95,20,,3.16,Percent of Total Billed Charges,20% of Total Billed Charges,3.95,20,,3.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.82,65,,10.256,Percent of Total Billed Charges,65% of Total Billed Charges,12.82,65,,10.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.95,53.67,
SUTURE A304H,90062255,CDM,272,RC,,,Outpatient,,,62.61,31.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.52,20,,10.016,Percent of Total Billed Charges,20% of Total Billed Charges,12.52,20,,10.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.52,20,,10.016,Percent of Total Billed Charges,20% of Total Billed Charges,12.52,20,,10.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.7,65,,32.56,Percent of Total Billed Charges,65% of Total Billed Charges,40.7,65,,32.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.52,53.67,
SUTURE G122H,90062256,CDM,272,RC,,,Outpatient,,,61.39,30.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.28,20,,9.824,Percent of Total Billed Charges,20% of Total Billed Charges,12.28,20,,9.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.28,20,,9.824,Percent of Total Billed Charges,20% of Total Billed Charges,12.28,20,,9.824,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.9,65,,31.92,Percent of Total Billed Charges,65% of Total Billed Charges,39.9,65,,31.92,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.28,53.67,
SUTURE Z371T,90062257,CDM,272,RC,,,Outpatient,,,60.43,30.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,20,,9.672,Percent of Total Billed Charges,20% of Total Billed Charges,12.09,20,,9.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,20,,9.672,Percent of Total Billed Charges,20% of Total Billed Charges,12.09,20,,9.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.28,65,,31.424,Percent of Total Billed Charges,65% of Total Billed Charges,39.28,65,,31.424,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,53.67,
SUTURE 662H,90062258,CDM,272,RC,,,Outpatient,,,39.43,19.72,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,20,,6.312,Percent of Total Billed Charges,20% of Total Billed Charges,7.89,20,,6.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,20,,6.312,Percent of Total Billed Charges,20% of Total Billed Charges,7.89,20,,6.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.63,65,,20.504,Percent of Total Billed Charges,65% of Total Billed Charges,25.63,65,,20.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,53.67,
SUTURE 1669H,90062259,CDM,272,RC,,,Outpatient,,,70.86,35.43,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,20,,11.336,Percent of Total Billed Charges,20% of Total Billed Charges,14.17,20,,11.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,20,,11.336,Percent of Total Billed Charges,20% of Total Billed Charges,14.17,20,,11.336,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.06,65,,36.848,Percent of Total Billed Charges,65% of Total Billed Charges,46.06,65,,36.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,53.67,
SUTURE J416H,90062260,CDM,272,RC,,,Outpatient,,,32.7,16.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.54,20,,5.232,Percent of Total Billed Charges,20% of Total Billed Charges,6.54,20,,5.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.54,20,,5.232,Percent of Total Billed Charges,20% of Total Billed Charges,6.54,20,,5.232,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.26,65,,17.008,Percent of Total Billed Charges,65% of Total Billed Charges,21.26,65,,17.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.54,53.67,
SUTURE VR494,90062261,CDM,272,RC,,,Outpatient,,,120.73,60.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.15,20,,19.32,Percent of Total Billed Charges,20% of Total Billed Charges,24.15,20,,19.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.15,20,,19.32,Percent of Total Billed Charges,20% of Total Billed Charges,24.15,20,,19.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.47,65,,62.776,Percent of Total Billed Charges,65% of Total Billed Charges,78.47,65,,62.776,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.15,78.47,
SUTURE J341H,90062262,CDM,272,RC,,,Outpatient,,,35.35,17.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,20,,5.656,Percent of Total Billed Charges,20% of Total Billed Charges,7.07,20,,5.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,20,,5.656,Percent of Total Billed Charges,20% of Total Billed Charges,7.07,20,,5.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,65,,18.384,Percent of Total Billed Charges,65% of Total Billed Charges,22.98,65,,18.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,53.67,
CATHETER TRAY SURGICAL 15FR,90062263,CDM,272,RC,,,Outpatient,,,25.18,12.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.04,20,,4.032,Percent of Total Billed Charges,20% of Total Billed Charges,5.04,20,,4.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.04,20,,4.032,Percent of Total Billed Charges,20% of Total Billed Charges,5.04,20,,4.032,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.37,65,,13.096,Percent of Total Billed Charges,65% of Total Billed Charges,16.37,65,,13.096,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.04,53.67,
DRAPES STERI-DRAPE SM 17X11,90062264,CDM,272,RC,,,Outpatient,,,13.85,6.93,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.77,20,,2.216,Percent of Total Billed Charges,20% of Total Billed Charges,2.77,20,,2.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.77,20,,2.216,Percent of Total Billed Charges,20% of Total Billed Charges,2.77,20,,2.216,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,65,,7.2,Percent of Total Billed Charges,65% of Total Billed Charges,9,65,,7.2,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.77,53.67,
C-ARM DRAPE 36X36,90062265,CDM,272,RC,,,Outpatient,,,9.53,4.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,20,,1.528,Percent of Total Billed Charges,20% of Total Billed Charges,1.91,20,,1.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,20,,1.528,Percent of Total Billed Charges,20% of Total Billed Charges,1.91,20,,1.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,65,,4.952,Percent of Total Billed Charges,65% of Total Billed Charges,6.19,65,,4.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,53.67,
SUTURE Y497G,90062266,CDM,272,RC,,,Outpatient,,,149.96,74.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.99,20,,23.992,Percent of Total Billed Charges,20% of Total Billed Charges,29.99,20,,23.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.99,20,,23.992,Percent of Total Billed Charges,20% of Total Billed Charges,29.99,20,,23.992,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.47,65,,77.976,Percent of Total Billed Charges,65% of Total Billed Charges,97.47,65,,77.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.99,97.47,
CAUTERY PENCIL 15',90062286,CDM,272,RC,,,Outpatient,,,235.46,117.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.09,20,,37.672,Percent of Total Billed Charges,20% of Total Billed Charges,47.09,20,,37.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.09,20,,37.672,Percent of Total Billed Charges,20% of Total Billed Charges,47.09,20,,37.672,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.05,65,,122.44,Percent of Total Billed Charges,65% of Total Billed Charges,153.05,65,,122.44,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.09,153.05,
ELECTRODE SS NEEDLE 6,90062287,CDM,272,RC,,,Outpatient,,,27.71,13.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,20,,4.432,Percent of Total Billed Charges,20% of Total Billed Charges,5.54,20,,4.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,20,,4.432,Percent of Total Billed Charges,20% of Total Billed Charges,5.54,20,,4.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.01,65,,14.408,Percent of Total Billed Charges,65% of Total Billed Charges,18.01,65,,14.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,53.67,
BOVIE PADS (ADULT),90062288,CDM,270,RC,,,Outpatient,,,33.17,16.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,20,,5.304,Percent of Total Billed Charges,20% of Total Billed Charges,6.63,20,,5.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,20,,5.304,Percent of Total Billed Charges,20% of Total Billed Charges,6.63,20,,5.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.56,65,,17.248,Percent of Total Billed Charges,65% of Total Billed Charges,21.56,65,,17.248,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,53.67,
NEEDLE TIP BOVIE INSULATED,90062291,CDM,272,RC,,,Outpatient,,,30.59,15.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.12,20,,4.896,Percent of Total Billed Charges,20% of Total Billed Charges,6.12,20,,4.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.12,20,,4.896,Percent of Total Billed Charges,20% of Total Billed Charges,6.12,20,,4.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.88,65,,15.904,Percent of Total Billed Charges,65% of Total Billed Charges,19.88,65,,15.904,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.12,53.67,
6.0 ENDOTRACH W/ STYLETTE CUFFED,90062747,CDM,272,RC,,,Outpatient,,,28.43,14.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.69,20,,4.552,Percent of Total Billed Charges,20% of Total Billed Charges,5.69,20,,4.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.69,20,,4.552,Percent of Total Billed Charges,20% of Total Billed Charges,5.69,20,,4.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.48,65,,14.784,Percent of Total Billed Charges,65% of Total Billed Charges,18.48,65,,14.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.69,53.67,
6.5 ENDOTRACH W/ STYLETTE CUFFED,90062748,CDM,272,RC,,,Outpatient,,,28.43,14.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.69,20,,4.552,Percent of Total Billed Charges,20% of Total Billed Charges,5.69,20,,4.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.69,20,,4.552,Percent of Total Billed Charges,20% of Total Billed Charges,5.69,20,,4.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.48,65,,14.784,Percent of Total Billed Charges,65% of Total Billed Charges,18.48,65,,14.784,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.69,53.67,
7.0 ENDOTRACH W/ STYLETTE CUFFED,90062749,CDM,272,RC,,,Outpatient,,,31.83,15.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,20,,5.096,Percent of Total Billed Charges,20% of Total Billed Charges,6.37,20,,5.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,20,,5.096,Percent of Total Billed Charges,20% of Total Billed Charges,6.37,20,,5.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,65,,16.552,Percent of Total Billed Charges,65% of Total Billed Charges,20.69,65,,16.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,53.67,
7.5 ENDOTRACH W/ STYLETTE CUFFED,90062750,CDM,272,RC,,,Outpatient,,,31.83,15.92,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,20,,5.096,Percent of Total Billed Charges,20% of Total Billed Charges,6.37,20,,5.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,20,,5.096,Percent of Total Billed Charges,20% of Total Billed Charges,6.37,20,,5.096,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,65,,16.552,Percent of Total Billed Charges,65% of Total Billed Charges,20.69,65,,16.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,53.67,
8.0 ENDOTRACH W/ STYLETTE CUFFED,90062751,CDM,272,RC,,,Outpatient,,,31.26,15.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.25,20,,5,Percent of Total Billed Charges,20% of Total Billed Charges,6.25,20,,5,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.25,20,,5,Percent of Total Billed Charges,20% of Total Billed Charges,6.25,20,,5,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.32,65,,16.256,Percent of Total Billed Charges,65% of Total Billed Charges,20.32,65,,16.256,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.25,53.67,
LMA SIZE 4,90062758,CDM,272,RC,,,Outpatient,,,53.87,26.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.77,20,,8.616,Percent of Total Billed Charges,20% of Total Billed Charges,10.77,20,,8.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.77,20,,8.616,Percent of Total Billed Charges,20% of Total Billed Charges,10.77,20,,8.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.02,65,,28.016,Percent of Total Billed Charges,65% of Total Billed Charges,35.02,65,,28.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.77,53.67,
LMA SIZE 3,90062759,CDM,272,RC,,,Outpatient,,,50.78,25.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,20,,8.128,Percent of Total Billed Charges,20% of Total Billed Charges,10.16,20,,8.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,20,,8.128,Percent of Total Billed Charges,20% of Total Billed Charges,10.16,20,,8.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.01,65,,26.408,Percent of Total Billed Charges,65% of Total Billed Charges,33.01,65,,26.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,53.67,
LMA SIZE 5,90062760,CDM,272,RC,,,Outpatient,,,50.78,25.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,20,,8.128,Percent of Total Billed Charges,20% of Total Billed Charges,10.16,20,,8.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,20,,8.128,Percent of Total Billed Charges,20% of Total Billed Charges,10.16,20,,8.128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.01,65,,26.408,Percent of Total Billed Charges,65% of Total Billed Charges,33.01,65,,26.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,53.67,
POSTIIONER FOAM HEAD,90062772,CDM,270,RC,,,Outpatient,,,67.26,33.63,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.45,20,,10.76,Percent of Total Billed Charges,20% of Total Billed Charges,13.45,20,,10.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.45,20,,10.76,Percent of Total Billed Charges,20% of Total Billed Charges,13.45,20,,10.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.72,65,,34.976,Percent of Total Billed Charges,65% of Total Billed Charges,43.72,65,,34.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.45,53.67,
STAPLER LINEAR 60-4.0,90062774,CDM,272,RC,,,Outpatient,,,847.28,423.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.46,20,,135.568,Percent of Total Billed Charges,20% of Total Billed Charges,169.46,20,,135.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.46,20,,135.568,Percent of Total Billed Charges,20% of Total Billed Charges,169.46,20,,135.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,550.73,65,,440.584,Percent of Total Billed Charges,65% of Total Billed Charges,550.73,65,,440.584,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,550.73,
STAPLER LINEAR 30-4.8,90062775,CDM,272,RC,,,Outpatient,,,819.27,409.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.85,20,,131.08,Percent of Total Billed Charges,20% of Total Billed Charges,163.85,20,,131.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.85,20,,131.08,Percent of Total Billed Charges,20% of Total Billed Charges,163.85,20,,131.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.53,65,,426.024,Percent of Total Billed Charges,65% of Total Billed Charges,532.53,65,,426.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,532.53,
STAPLER LINEAR 30-2.5,90062776,CDM,272,RC,,,Outpatient,,,899.08,449.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.82,20,,143.856,Percent of Total Billed Charges,20% of Total Billed Charges,179.82,20,,143.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.82,20,,143.856,Percent of Total Billed Charges,20% of Total Billed Charges,179.82,20,,143.856,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,584.4,65,,467.52,Percent of Total Billed Charges,65% of Total Billed Charges,584.4,65,,467.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,584.4,
BAIR HUGGER LOWER,90062780,CDM,272,RC,,,Outpatient,,,59.69,29.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.94,20,,9.552,Percent of Total Billed Charges,20% of Total Billed Charges,11.94,20,,9.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.94,20,,9.552,Percent of Total Billed Charges,20% of Total Billed Charges,11.94,20,,9.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.8,65,,31.04,Percent of Total Billed Charges,65% of Total Billed Charges,38.8,65,,31.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.94,53.67,
BAIR HUGGER UPPER,90062781,CDM,272,RC,,,Outpatient,,,90.16,45.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,20,,14.424,Percent of Total Billed Charges,20% of Total Billed Charges,18.03,20,,14.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,20,,14.424,Percent of Total Billed Charges,20% of Total Billed Charges,18.03,20,,14.424,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.6,65,,46.88,Percent of Total Billed Charges,65% of Total Billed Charges,58.6,65,,46.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.03,58.6,
MESH LG LEFT 3D,90062782,CDM,278,RC,C1781,HCPCS,Outpatient,,,755.42,377.71,,491.02,65,,392.816,Percent of Total Billed Charges,65% of Total Billed Charges,513.69,68,,410.952,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.08,20,,120.864,Percent of Total Billed Charges,20% of Total Billed Charges,151.08,20,,120.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.08,20,,120.864,Percent of Total Billed Charges,20% of Total Billed Charges,151.08,20,,120.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,604.34,80,,483.472,Percent of Total Billed Charges,80% of Total Billed Charges,642.11,85,,513.688,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,642.11,
MESH MD LEFT 3D,90062783,CDM,278,RC,,,Outpatient,,,701.77,350.89,,,,,,Other,Not Seperately Reimbuasble,477.2,68,,381.76,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.35,20,,112.28,Percent of Total Billed Charges,20% of Total Billed Charges,140.35,20,,112.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.35,20,,112.28,Percent of Total Billed Charges,20% of Total Billed Charges,140.35,20,,112.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,561.42,80,,449.136,Percent of Total Billed Charges,80% of Total Billed Charges,596.5,85,,477.2,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,596.5,
MESH MD RIGHT 3D,90062784,CDM,278,RC,C1781,HCPCS,Outpatient,,,701.77,350.89,,456.15,65,,364.92,Percent of Total Billed Charges,65% of Total Billed Charges,477.2,68,,381.76,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.35,20,,112.28,Percent of Total Billed Charges,20% of Total Billed Charges,140.35,20,,112.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.35,20,,112.28,Percent of Total Billed Charges,20% of Total Billed Charges,140.35,20,,112.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,561.42,80,,449.136,Percent of Total Billed Charges,80% of Total Billed Charges,596.5,85,,477.2,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,596.5,
MESH RT LRG 3D,90062785,CDM,278,RC,C1781,HCPCS,Outpatient,,,755.42,377.71,,491.02,65,,392.816,Percent of Total Billed Charges,65% of Total Billed Charges,513.69,68,,410.952,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.08,20,,120.864,Percent of Total Billed Charges,20% of Total Billed Charges,151.08,20,,120.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.08,20,,120.864,Percent of Total Billed Charges,20% of Total Billed Charges,151.08,20,,120.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,604.34,80,,483.472,Percent of Total Billed Charges,80% of Total Billed Charges,642.11,85,,513.688,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,642.11,
MESH MARLEX 1x4,90062786,CDM,278,RC,C1781,HCPCS,Outpatient,,,255.25,127.63,,165.91,65,,132.728,Percent of Total Billed Charges,65% of Total Billed Charges,173.57,68,,138.856,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.05,20,,40.84,Percent of Total Billed Charges,20% of Total Billed Charges,51.05,20,,40.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.05,20,,40.84,Percent of Total Billed Charges,20% of Total Billed Charges,51.05,20,,40.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.2,80,,163.36,Percent of Total Billed Charges,80% of Total Billed Charges,216.96,85,,173.568,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.05,216.96,
MESH HERNIA MD 4.5,90062787,CDM,278,RC,C1781,HCPCS,Outpatient,,,2540.8,1270.40,,1651.52,65,,1321.216,Percent of Total Billed Charges,65% of Total Billed Charges,1727.74,68,,1382.192,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,508.16,20,,406.528,Percent of Total Billed Charges,20% of Total Billed Charges,508.16,20,,406.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,508.16,20,,406.528,Percent of Total Billed Charges,20% of Total Billed Charges,508.16,20,,406.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2032.64,80,,1626.112,Percent of Total Billed Charges,80% of Total Billed Charges,2159.68,85,,1727.744,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,2159.68,
MESH HERNIA UMB 20x15,90062788,CDM,278,RC,C1781,HCPCS,Outpatient,,,2190.38,1095.19,,1423.75,65,,1139,Percent of Total Billed Charges,65% of Total Billed Charges,1489.46,68,,1191.568,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.08,20,,350.464,Percent of Total Billed Charges,20% of Total Billed Charges,438.08,20,,350.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.08,20,,350.464,Percent of Total Billed Charges,20% of Total Billed Charges,438.08,20,,350.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1752.3,80,,1401.84,Percent of Total Billed Charges,80% of Total Billed Charges,1861.82,85,,1489.456,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,1861.82,
MESH HERNIA UMB 30x20,90062789,CDM,278,RC,C1781,HCPCS,Outpatient,,,3728.31,1864.16,,2423.4,65,,1938.72,Percent of Total Billed Charges,65% of Total Billed Charges,2535.25,68,,2028.2,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745.66,20,,596.528,Percent of Total Billed Charges,20% of Total Billed Charges,745.66,20,,596.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745.66,20,,596.528,Percent of Total Billed Charges,20% of Total Billed Charges,745.66,20,,596.528,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2982.65,80,,2386.12,Percent of Total Billed Charges,80% of Total Billed Charges,3169.06,85,,2535.248,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,3169.06,
URETERAL CATHETER OPEN END,90062790,CDM,272,RC,,,Outpatient,,,167.41,83.71,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,20,,26.784,Percent of Total Billed Charges,20% of Total Billed Charges,33.48,20,,26.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,20,,26.784,Percent of Total Billed Charges,20% of Total Billed Charges,33.48,20,,26.784,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.82,65,,87.056,Percent of Total Billed Charges,65% of Total Billed Charges,108.82,65,,87.056,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.48,108.82,
RAYTEC RAY SPONGE 4X4,90062797,CDM,272,RC,,,Outpatient,,,7.95,3.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,1.59,20,,1.272,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.17,65,,4.136,Percent of Total Billed Charges,65% of Total Billed Charges,5.17,65,,4.136,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,53.67,
SURGIFOAM 3X4,90062801,CDM,272,RC,,,Outpatient,,,210.33,105.17,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.07,20,,33.656,Percent of Total Billed Charges,20% of Total Billed Charges,42.07,20,,33.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.07,20,,33.656,Percent of Total Billed Charges,20% of Total Billed Charges,42.07,20,,33.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.71,65,,109.368,Percent of Total Billed Charges,65% of Total Billed Charges,136.71,65,,109.368,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.07,136.71,
MED CLIP APPLIER,90062802,CDM,272,RC,,,Outpatient,,,546.74,273.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.35,20,,87.48,Percent of Total Billed Charges,20% of Total Billed Charges,109.35,20,,87.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.35,20,,87.48,Percent of Total Billed Charges,20% of Total Billed Charges,109.35,20,,87.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.38,65,,284.304,Percent of Total Billed Charges,65% of Total Billed Charges,355.38,65,,284.304,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,355.38,
LG CLIP APPLIER,90062803,CDM,272,RC,,,Outpatient,,,534.48,267.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.9,20,,85.52,Percent of Total Billed Charges,20% of Total Billed Charges,106.9,20,,85.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.9,20,,85.52,Percent of Total Billed Charges,20% of Total Billed Charges,106.9,20,,85.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.41,65,,277.928,Percent of Total Billed Charges,65% of Total Billed Charges,347.41,65,,277.928,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,347.41,
TEGADERM FOAM 4X4,90062804,CDM,272,RC,,,Outpatient,,,40.18,20.09,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.04,20,,6.432,Percent of Total Billed Charges,20% of Total Billed Charges,8.04,20,,6.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.04,20,,6.432,Percent of Total Billed Charges,20% of Total Billed Charges,8.04,20,,6.432,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.12,65,,20.896,Percent of Total Billed Charges,65% of Total Billed Charges,26.12,65,,20.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.04,53.67,
SUTURE VICRYL 0,90062805,CDM,272,RC,,,Outpatient,,,56.56,28.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.31,20,,9.048,Percent of Total Billed Charges,20% of Total Billed Charges,11.31,20,,9.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.31,20,,9.048,Percent of Total Billed Charges,20% of Total Billed Charges,11.31,20,,9.048,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,65,,29.408,Percent of Total Billed Charges,65% of Total Billed Charges,36.76,65,,29.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.31,53.67,
T-TUBE 12FRx18FR,90062806,CDM,272,RC,,,Outpatient,,,180.78,90.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.16,20,,28.928,Percent of Total Billed Charges,20% of Total Billed Charges,36.16,20,,28.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.16,20,,28.928,Percent of Total Billed Charges,20% of Total Billed Charges,36.16,20,,28.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.51,65,,94.008,Percent of Total Billed Charges,65% of Total Billed Charges,117.51,65,,94.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.16,117.51,
T-TUBE 14FRx18,90062807,CDM,272,RC,,,Outpatient,,,183.43,91.72,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.69,20,,29.352,Percent of Total Billed Charges,20% of Total Billed Charges,36.69,20,,29.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.69,20,,29.352,Percent of Total Billed Charges,20% of Total Billed Charges,36.69,20,,29.352,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.23,65,,95.384,Percent of Total Billed Charges,65% of Total Billed Charges,119.23,65,,95.384,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.69,119.23,
CLOSED WOUND BULB (JP DRAIN),90062808,CDM,272,RC,,,Outpatient,,,34.67,17.34,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,20,,5.544,Percent of Total Billed Charges,20% of Total Billed Charges,6.93,20,,5.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,20,,5.544,Percent of Total Billed Charges,20% of Total Billed Charges,6.93,20,,5.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.54,65,,18.032,Percent of Total Billed Charges,65% of Total Billed Charges,22.54,65,,18.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,53.67,
PURACOL PLUS AG+ DRESSING,90062810,CDM,272,RC,,,Outpatient,,,72.32,36.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,14.46,20,,11.568,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.01,65,,37.608,Percent of Total Billed Charges,65% of Total Billed Charges,47.01,65,,37.608,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.46,53.67,
PEG 24 PULL,90062811,CDM,272,RC,,,Outpatient,,,293.29,146.65,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.66,20,,46.928,Percent of Total Billed Charges,20% of Total Billed Charges,58.66,20,,46.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.66,20,,46.928,Percent of Total Billed Charges,20% of Total Billed Charges,58.66,20,,46.928,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.64,65,,152.512,Percent of Total Billed Charges,65% of Total Billed Charges,190.64,65,,152.512,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,190.64,
25G INTERJECT CLEAR,90062813,CDM,272,RC,,,Outpatient,,,215.45,107.73,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,20,,34.472,Percent of Total Billed Charges,20% of Total Billed Charges,43.09,20,,34.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,20,,34.472,Percent of Total Billed Charges,20% of Total Billed Charges,43.09,20,,34.472,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.04,65,,112.032,Percent of Total Billed Charges,65% of Total Billed Charges,140.04,65,,112.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,140.04,
INSUFFLATION TUBING 20LT HIGH FLOW,90062820,CDM,272,RC,,,Outpatient,,,146.84,73.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.37,20,,23.496,Percent of Total Billed Charges,20% of Total Billed Charges,29.37,20,,23.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.37,20,,23.496,Percent of Total Billed Charges,20% of Total Billed Charges,29.37,20,,23.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.45,65,,76.36,Percent of Total Billed Charges,65% of Total Billed Charges,95.45,65,,76.36,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.37,95.45,
LINEAR REFILL 30MM,90062821,CDM,272,RC,,,Outpatient,,,355.39,177.70,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.08,20,,56.864,Percent of Total Billed Charges,20% of Total Billed Charges,71.08,20,,56.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.08,20,,56.864,Percent of Total Billed Charges,20% of Total Billed Charges,71.08,20,,56.864,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231,65,,184.8,Percent of Total Billed Charges,65% of Total Billed Charges,231,65,,184.8,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,231,
STAPLER REFILL LENEAR 60MM,90062822,CDM,272,RC,,,Outpatient,,,382.79,191.40,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.56,20,,61.248,Percent of Total Billed Charges,20% of Total Billed Charges,76.56,20,,61.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.56,20,,61.248,Percent of Total Billed Charges,20% of Total Billed Charges,76.56,20,,61.248,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.81,65,,199.048,Percent of Total Billed Charges,65% of Total Billed Charges,248.81,65,,199.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,248.81,
STAPLER REFILL VASC. 30MM,90062823,CDM,272,RC,,,Outpatient,,,365.37,182.69,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.07,20,,58.456,Percent of Total Billed Charges,20% of Total Billed Charges,73.07,20,,58.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.07,20,,58.456,Percent of Total Billed Charges,20% of Total Billed Charges,73.07,20,,58.456,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.49,65,,189.992,Percent of Total Billed Charges,65% of Total Billed Charges,237.49,65,,189.992,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,237.49,
5X100 Kii DUAL PACK,90062824,CDM,272,RC,,,Outpatient,,,122.77,61.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.55,20,,19.64,Percent of Total Billed Charges,20% of Total Billed Charges,24.55,20,,19.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.55,20,,19.64,Percent of Total Billed Charges,20% of Total Billed Charges,24.55,20,,19.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,65,,63.84,Percent of Total Billed Charges,65% of Total Billed Charges,79.8,65,,63.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.55,79.8,
12X100 BALLOON BLUNT TIP,90062825,CDM,272,RC,,,Outpatient,,,124.63,62.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.93,81.01,
OPTICAL ACCESS SYSTEM,90062826,CDM,272,RC,,,Outpatient,,,124.63,62.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,24.93,20,,19.944,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,81.01,65,,64.808,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.93,81.01,
12X100 Kii SLEEVE,90062827,CDM,272,RC,,,Outpatient,,,86.45,43.23,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,20,,13.832,Percent of Total Billed Charges,20% of Total Billed Charges,17.29,20,,13.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,20,,13.832,Percent of Total Billed Charges,20% of Total Billed Charges,17.29,20,,13.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.19,65,,44.952,Percent of Total Billed Charges,65% of Total Billed Charges,56.19,65,,44.952,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,56.19,
5X100 Kii SLEEVE,90062828,CDM,272,RC,,,Outpatient,,,54.38,27.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.88,20,,8.704,Percent of Total Billed Charges,20% of Total Billed Charges,10.88,20,,8.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.88,20,,8.704,Percent of Total Billed Charges,20% of Total Billed Charges,10.88,20,,8.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.35,65,,28.28,Percent of Total Billed Charges,65% of Total Billed Charges,35.35,65,,28.28,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.88,53.67,
10MM RETRIEVAL,90062829,CDM,272,RC,,,Outpatient,,,226.6,113.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,147.29,
FINE FUSION DEVICE,90062830,CDM,272,RC,,,Outpatient,,,634.74,317.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.95,20,,101.56,Percent of Total Billed Charges,20% of Total Billed Charges,126.95,20,,101.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.95,20,,101.56,Percent of Total Billed Charges,20% of Total Billed Charges,126.95,20,,101.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.58,65,,330.064,Percent of Total Billed Charges,65% of Total Billed Charges,412.58,65,,330.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,412.58,
MARYLAND FUSION,90062831,CDM,272,RC,,,Outpatient,,,226.6,113.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,45.32,20,,36.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,147.29,65,,117.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,147.29,
UNIV. CLIP APPLIER,90062832,CDM,272,RC,,,Outpatient,,,255,127.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,20,,40.8,Percent of Total Billed Charges,20% of Total Billed Charges,51,20,,40.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,20,,40.8,Percent of Total Billed Charges,20% of Total Billed Charges,51,20,,40.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.75,65,,132.6,Percent of Total Billed Charges,65% of Total Billed Charges,165.75,65,,132.6,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,165.75,
LATIS. GRASP,90062833,CDM,272,RC,,,Outpatient,,,254.93,127.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.7,65,,132.56,Percent of Total Billed Charges,65% of Total Billed Charges,165.7,65,,132.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,165.7,
LAPRO DISSECTOR,90062834,CDM,272,RC,,,Outpatient,,,254.93,127.47,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,50.99,20,,40.792,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.7,65,,132.56,Percent of Total Billed Charges,65% of Total Billed Charges,165.7,65,,132.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.99,165.7,
LAPRO SCISSORS,90062835,CDM,272,RC,,,Outpatient,,,215.27,107.64,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.05,20,,34.44,Percent of Total Billed Charges,20% of Total Billed Charges,43.05,20,,34.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.05,20,,34.44,Percent of Total Billed Charges,20% of Total Billed Charges,43.05,20,,34.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,65,,111.944,Percent of Total Billed Charges,65% of Total Billed Charges,139.93,65,,111.944,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.05,139.93,
ELECTRO PROBE L-HOOK,90062836,CDM,272,RC,,,Outpatient,,,186.69,93.35,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.34,20,,29.872,Percent of Total Billed Charges,20% of Total Billed Charges,37.34,20,,29.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.34,20,,29.872,Percent of Total Billed Charges,20% of Total Billed Charges,37.34,20,,29.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.35,65,,97.08,Percent of Total Billed Charges,65% of Total Billed Charges,121.35,65,,97.08,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.34,121.35,
3M IOBAN 2 23x23,90062837,CDM,272,RC,,,Outpatient,,,96.37,48.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.27,20,,15.416,Percent of Total Billed Charges,20% of Total Billed Charges,19.27,20,,15.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.27,20,,15.416,Percent of Total Billed Charges,20% of Total Billed Charges,19.27,20,,15.416,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.64,65,,50.112,Percent of Total Billed Charges,65% of Total Billed Charges,62.64,65,,50.112,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.27,62.64,
CARTER-THOMASON CLOSURE,90062838,CDM,272,RC,,,Outpatient,,,370.62,185.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.12,20,,59.296,Percent of Total Billed Charges,20% of Total Billed Charges,74.12,20,,59.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.12,20,,59.296,Percent of Total Billed Charges,20% of Total Billed Charges,74.12,20,,59.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.9,65,,192.72,Percent of Total Billed Charges,65% of Total Billed Charges,240.9,65,,192.72,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,240.9,
SUTURE D9566,90062839,CDM,272,RC,,,Outpatient,,,274.34,137.17,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.87,20,,43.896,Percent of Total Billed Charges,20% of Total Billed Charges,54.87,20,,43.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.87,20,,43.896,Percent of Total Billed Charges,20% of Total Billed Charges,54.87,20,,43.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.32,65,,142.656,Percent of Total Billed Charges,65% of Total Billed Charges,178.32,65,,142.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,178.32,
SUTURE 8833H,90062840,CDM,272,RC,,,Outpatient,,,35.69,17.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.14,20,,5.712,Percent of Total Billed Charges,20% of Total Billed Charges,7.14,20,,5.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.14,20,,5.712,Percent of Total Billed Charges,20% of Total Billed Charges,7.14,20,,5.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,65,,18.56,Percent of Total Billed Charges,65% of Total Billed Charges,23.2,65,,18.56,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.14,53.67,
SUTURE 8417H,90062841,CDM,272,RC,,,Outpatient,,,35.02,17.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.76,65,,18.208,Percent of Total Billed Charges,65% of Total Billed Charges,22.76,65,,18.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,53.67,
SUTURE D6929,90062842,CDM,272,RC,,,Outpatient,,,173.04,86.52,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,34.61,20,,27.688,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,112.48,65,,89.984,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.61,112.48,
SUTURE SA85H,90062843,CDM,272,RC,,,Outpatient,,,26.88,13.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,5.38,20,,4.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.47,65,,13.976,Percent of Total Billed Charges,65% of Total Billed Charges,17.47,65,,13.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,53.67,
SUTURE D8552,90062844,CDM,272,RC,,,Outpatient,,,220.99,110.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.2,20,,35.36,Percent of Total Billed Charges,20% of Total Billed Charges,44.2,20,,35.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.2,20,,35.36,Percent of Total Billed Charges,20% of Total Billed Charges,44.2,20,,35.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.64,65,,114.912,Percent of Total Billed Charges,65% of Total Billed Charges,143.64,65,,114.912,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.2,143.64,
SUTURE D8551,90062845,CDM,272,RC,,,Outpatient,,,257.76,128.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.55,20,,41.24,Percent of Total Billed Charges,20% of Total Billed Charges,51.55,20,,41.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.55,20,,41.24,Percent of Total Billed Charges,20% of Total Billed Charges,51.55,20,,41.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.54,65,,134.032,Percent of Total Billed Charges,65% of Total Billed Charges,167.54,65,,134.032,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.55,167.54,
SUTURE D7414,90062846,CDM,272,RC,,,Outpatient,,,176.95,88.48,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.39,20,,28.312,Percent of Total Billed Charges,20% of Total Billed Charges,35.39,20,,28.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.39,20,,28.312,Percent of Total Billed Charges,20% of Total Billed Charges,35.39,20,,28.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.02,65,,92.016,Percent of Total Billed Charges,65% of Total Billed Charges,115.02,65,,92.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.39,115.02,
SUTURE MCP523H,90062847,CDM,272,RC,,,Outpatient,,,42.02,21.01,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,20,,6.72,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,20,,6.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,20,,6.72,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,20,,6.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.31,65,,21.848,Percent of Total Billed Charges,65% of Total Billed Charges,27.31,65,,21.848,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,53.67,
SUTURE Y494G,90062848,CDM,272,RC,,,Outpatient,,,64.53,32.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.91,20,,10.328,Percent of Total Billed Charges,20% of Total Billed Charges,12.91,20,,10.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.91,20,,10.328,Percent of Total Billed Charges,20% of Total Billed Charges,12.91,20,,10.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.94,65,,33.552,Percent of Total Billed Charges,65% of Total Billed Charges,41.94,65,,33.552,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.91,53.67,
SUTURE Y426H,90062849,CDM,272,RC,,,Outpatient,,,62.11,31.06,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.42,20,,9.936,Percent of Total Billed Charges,20% of Total Billed Charges,12.42,20,,9.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.42,20,,9.936,Percent of Total Billed Charges,20% of Total Billed Charges,12.42,20,,9.936,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.37,65,,32.296,Percent of Total Billed Charges,65% of Total Billed Charges,40.37,65,,32.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.42,53.67,
SUTURE D7463,90062850,CDM,272,RC,,,Outpatient,,,210.84,105.42,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.17,20,,33.736,Percent of Total Billed Charges,20% of Total Billed Charges,42.17,20,,33.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.17,20,,33.736,Percent of Total Billed Charges,20% of Total Billed Charges,42.17,20,,33.736,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.05,65,,109.64,Percent of Total Billed Charges,65% of Total Billed Charges,137.05,65,,109.64,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.17,137.05,
DERMABOND SURGICAL 0.7ML,90062851,CDM,272,RC,,,Outpatient,,,98.16,49.08,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.63,20,,15.704,Percent of Total Billed Charges,20% of Total Billed Charges,19.63,20,,15.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.63,20,,15.704,Percent of Total Billed Charges,20% of Total Billed Charges,19.63,20,,15.704,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.8,65,,51.04,Percent of Total Billed Charges,65% of Total Billed Charges,63.8,65,,51.04,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.63,63.8,
MAPLESON CIRCUIT KIT,90062852,CDM,272,RC,,,Outpatient,,,177.06,88.53,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.41,20,,28.328,Percent of Total Billed Charges,20% of Total Billed Charges,35.41,20,,28.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.41,20,,28.328,Percent of Total Billed Charges,20% of Total Billed Charges,35.41,20,,28.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.09,65,,92.072,Percent of Total Billed Charges,65% of Total Billed Charges,115.09,65,,92.072,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.41,115.09,
EPIDURAL KIT,90062853,CDM,272,RC,,,Outpatient,,,382.39,191.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.48,20,,61.184,Percent of Total Billed Charges,20% of Total Billed Charges,76.48,20,,61.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.48,20,,61.184,Percent of Total Billed Charges,20% of Total Billed Charges,76.48,20,,61.184,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.55,65,,198.84,Percent of Total Billed Charges,65% of Total Billed Charges,248.55,65,,198.84,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,248.55,
SIGMOIDOSCOPE KIT,90062854,CDM,272,RC,,,Outpatient,,,157.44,78.72,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.49,20,,25.192,Percent of Total Billed Charges,20% of Total Billed Charges,31.49,20,,25.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.49,20,,25.192,Percent of Total Billed Charges,20% of Total Billed Charges,31.49,20,,25.192,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.34,65,,81.872,Percent of Total Billed Charges,65% of Total Billed Charges,102.34,65,,81.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.49,102.34,
KITTNER DISSECTOR SPONGE 5PK,90062855,CDM,272,RC,,,Outpatient,,,19,9.50,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,53.67,
LONE STAR HOOKS,90062858,CDM,272,RC,,,Outpatient,,,304.47,152.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.89,20,,48.712,Percent of Total Billed Charges,20% of Total Billed Charges,60.89,20,,48.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.89,20,,48.712,Percent of Total Billed Charges,20% of Total Billed Charges,60.89,20,,48.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.91,65,,158.328,Percent of Total Billed Charges,65% of Total Billed Charges,197.91,65,,158.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,197.91,
LONE STAR RETRACTOR 14.1 X 14.1,90062859,CDM,272,RC,,,Outpatient,,,304.47,152.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.89,20,,48.712,Percent of Total Billed Charges,20% of Total Billed Charges,60.89,20,,48.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.89,20,,48.712,Percent of Total Billed Charges,20% of Total Billed Charges,60.89,20,,48.712,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.91,65,,158.328,Percent of Total Billed Charges,65% of Total Billed Charges,197.91,65,,158.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,197.91,
3M IOBAN 2 13X13,90062860,CDM,272,RC,,,Outpatient,,,56.38,28.19,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,20,,9.024,Percent of Total Billed Charges,20% of Total Billed Charges,11.28,20,,9.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,20,,9.024,Percent of Total Billed Charges,20% of Total Billed Charges,11.28,20,,9.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.65,65,,29.32,Percent of Total Billed Charges,65% of Total Billed Charges,36.65,65,,29.32,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,53.67,
BEACH CHAIR DRAPE PK,90062861,CDM,272,RC,,,Outpatient,,,102.92,51.46,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,20,,16.464,Percent of Total Billed Charges,20% of Total Billed Charges,20.58,20,,16.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,20,,16.464,Percent of Total Billed Charges,20% of Total Billed Charges,20.58,20,,16.464,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.9,65,,53.52,Percent of Total Billed Charges,65% of Total Billed Charges,66.9,65,,53.52,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,66.9,
LUBRICATING JELLY 2oz,90062862,CDM,271,RC,,,Outpatient,,,15.76,7.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.15,20,,2.52,Percent of Total Billed Charges,20% of Total Billed Charges,3.15,20,,2.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.15,20,,2.52,Percent of Total Billed Charges,20% of Total Billed Charges,3.15,20,,2.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.24,65,,8.192,Percent of Total Billed Charges,65% of Total Billed Charges,10.24,65,,8.192,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.15,53.67,
BETADINE SCRUB PREP TRAY,90062863,CDM,272,RC,,,Outpatient,,,39.91,19.96,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.98,20,,6.384,Percent of Total Billed Charges,20% of Total Billed Charges,7.98,20,,6.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.98,20,,6.384,Percent of Total Billed Charges,20% of Total Billed Charges,7.98,20,,6.384,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.94,65,,20.752,Percent of Total Billed Charges,65% of Total Billed Charges,25.94,65,,20.752,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.98,53.67,
SURGICAL STOCKINETTE ST,90062864,CDM,272,RC,,,Outpatient,,,81.66,40.83,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.33,20,,13.064,Percent of Total Billed Charges,20% of Total Billed Charges,16.33,20,,13.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.33,20,,13.064,Percent of Total Billed Charges,20% of Total Billed Charges,16.33,20,,13.064,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,65,,42.464,Percent of Total Billed Charges,65% of Total Billed Charges,53.08,65,,42.464,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.33,53.67,
VOYANT OPEN FUSION,90062867,CDM,272,RC,,,Outpatient,,,634.74,317.37,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.95,20,,101.56,Percent of Total Billed Charges,20% of Total Billed Charges,126.95,20,,101.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.95,20,,101.56,Percent of Total Billed Charges,20% of Total Billed Charges,126.95,20,,101.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.58,65,,330.064,Percent of Total Billed Charges,65% of Total Billed Charges,412.58,65,,330.064,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,412.58,
SUTURE 664G,90062869,CDM,272,RC,,,Outpatient,,,22.61,11.31,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,20,,3.616,Percent of Total Billed Charges,20% of Total Billed Charges,4.52,20,,3.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,20,,3.616,Percent of Total Billed Charges,20% of Total Billed Charges,4.52,20,,3.616,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,65,,11.76,Percent of Total Billed Charges,65% of Total Billed Charges,14.7,65,,11.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,53.67,
CORD BIPOLOR CAUTERY CORD STERILE,90062870,CDM,272,RC,,,Outpatient,,,51.96,25.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.39,20,,8.312,Percent of Total Billed Charges,20% of Total Billed Charges,10.39,20,,8.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.39,20,,8.312,Percent of Total Billed Charges,20% of Total Billed Charges,10.39,20,,8.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.77,65,,27.016,Percent of Total Billed Charges,65% of Total Billed Charges,33.77,65,,27.016,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.39,53.67,
SUTURE + PS-2 3-0 18,90062871,CDM,272,RC,,,Outpatient,,,61.95,30.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,20,,9.912,Percent of Total Billed Charges,20% of Total Billed Charges,12.39,20,,9.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,20,,9.912,Percent of Total Billed Charges,20% of Total Billed Charges,12.39,20,,9.912,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.27,65,,32.216,Percent of Total Billed Charges,65% of Total Billed Charges,40.27,65,,32.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,53.67,
MESH 6 X6  PROLENE,90062872,CDM,278,RC,C1781,HCPCS,Outpatient,,,701.95,350.98,,456.27,65,,365.016,Percent of Total Billed Charges,65% of Total Billed Charges,477.33,68,,381.864,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.39,20,,112.312,Percent of Total Billed Charges,20% of Total Billed Charges,140.39,20,,112.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.39,20,,112.312,Percent of Total Billed Charges,20% of Total Billed Charges,140.39,20,,112.312,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,561.56,80,,449.248,Percent of Total Billed Charges,80% of Total Billed Charges,596.66,85,,477.328,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,596.66,
DUAL CANNULA o2/cO2 14FT,90062874,CDM,272,RC,,,Outpatient,,,44.19,22.10,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.84,20,,7.072,Percent of Total Billed Charges,20% of Total Billed Charges,8.84,20,,7.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.84,20,,7.072,Percent of Total Billed Charges,20% of Total Billed Charges,8.84,20,,7.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.72,65,,22.976,Percent of Total Billed Charges,65% of Total Billed Charges,28.72,65,,22.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.84,53.67,
ART CATHERIZATION KIT,90062876,CDM,272,RC,,,Outpatient,,,219.18,109.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.84,20,,35.072,Percent of Total Billed Charges,20% of Total Billed Charges,43.84,20,,35.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.84,20,,35.072,Percent of Total Billed Charges,20% of Total Billed Charges,43.84,20,,35.072,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.47,65,,113.976,Percent of Total Billed Charges,65% of Total Billed Charges,142.47,65,,113.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.84,142.47,
ARTERIAL LINE RADIAL TRAY,90062877,CDM,272,RC,,,Outpatient,,,478.64,239.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.73,20,,76.584,Percent of Total Billed Charges,20% of Total Billed Charges,95.73,20,,76.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.73,20,,76.584,Percent of Total Billed Charges,20% of Total Billed Charges,95.73,20,,76.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.12,65,,248.896,Percent of Total Billed Charges,65% of Total Billed Charges,311.12,65,,248.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,311.12,
CATH SEROMACATH DRAIN,90062878,CDM,272,RC,,,Outpatient,,,435.59,217.80,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.12,20,,69.696,Percent of Total Billed Charges,20% of Total Billed Charges,87.12,20,,69.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.12,20,,69.696,Percent of Total Billed Charges,20% of Total Billed Charges,87.12,20,,69.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.13,65,,226.504,Percent of Total Billed Charges,65% of Total Billed Charges,283.13,65,,226.504,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,283.13,
STRYKEFLOW II SUCTION IRRIG DISP. TIP,90062879,CDM,272,RC,,,Outpatient,,,478.64,239.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.73,20,,76.584,Percent of Total Billed Charges,20% of Total Billed Charges,95.73,20,,76.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.73,20,,76.584,Percent of Total Billed Charges,20% of Total Billed Charges,95.73,20,,76.584,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.12,65,,248.896,Percent of Total Billed Charges,65% of Total Billed Charges,311.12,65,,248.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,311.12,
SPINAL NEEDLE STERILE 22G X 3.5,90062883,CDM,271,RC,,,Outpatient,,,16.58,8.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.78,65,,8.624,Percent of Total Billed Charges,65% of Total Billed Charges,10.78,65,,8.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,53.67,
SPINAL NEEDLE STERILE 25G,90062884,CDM,271,RC,,,Outpatient,,,16.58,8.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.78,65,,8.624,Percent of Total Billed Charges,65% of Total Billed Charges,10.78,65,,8.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,53.67,
NEEDLE 22GX1.5,90062885,CDM,271,RC,,,Outpatient,,,16.58,8.29,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,3.32,20,,2.656,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.78,65,,8.624,Percent of Total Billed Charges,65% of Total Billed Charges,10.78,65,,8.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,53.67,
VEINLITE REPLACEMENT COVERS,90062886,CDM,270,RC,,,Outpatient,,,68.08,34.04,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,13.62,20,,10.896,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.25,65,,35.4,Percent of Total Billed Charges,65% of Total Billed Charges,44.25,65,,35.4,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,53.67,
LMA SIZE 2,90062887,CDM,272,RC,,,Outpatient,,,65.96,32.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.87,65,,34.296,Percent of Total Billed Charges,65% of Total Billed Charges,42.87,65,,34.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,53.67,
XEROFORM 1X8,90062888,CDM,272,RC,,,Outpatient,,,3.5,1.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,20,,0.56,Percent of Total Billed Charges,20% of Total Billed Charges,0.7,20,,0.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,20,,0.56,Percent of Total Billed Charges,20% of Total Billed Charges,0.7,20,,0.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,65,,1.824,Percent of Total Billed Charges,65% of Total Billed Charges,2.28,65,,1.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,53.67,
PLUG & PATCH LARGE,90062889,CDM,278,RC,,,Outpatient,,,450.01,225.01,,,,,,Other,Not Seperately Reimbuasble,306.01,68,,244.808,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,90,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,90,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.01,80,,288.008,Percent of Total Billed Charges,80% of Total Billed Charges,382.51,85,,306.008,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,382.51,
PLUG & PATCH XL,90062890,CDM,278,RC,,,Outpatient,,,518.91,259.46,,,,,,Other,Not Seperately Reimbuasble,352.86,68,,282.288,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.78,20,,83.024,Percent of Total Billed Charges,20% of Total Billed Charges,103.78,20,,83.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.78,20,,83.024,Percent of Total Billed Charges,20% of Total Billed Charges,103.78,20,,83.024,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,415.13,80,,332.104,Percent of Total Billed Charges,80% of Total Billed Charges,441.07,85,,352.856,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,441.07,
PLUG & PATCH SMALL,90062891,CDM,278,RC,,,Outpatient,,,441.87,220.94,,,,,,Other,Not Seperately Reimbuasble,300.47,68,,240.376,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.37,20,,70.696,Percent of Total Billed Charges,20% of Total Billed Charges,88.37,20,,70.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.37,20,,70.696,Percent of Total Billed Charges,20% of Total Billed Charges,88.37,20,,70.696,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,353.5,80,,282.8,Percent of Total Billed Charges,80% of Total Billed Charges,375.59,85,,300.472,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,375.59,
PLUG & PATCH MED,90062892,CDM,278,RC,,,Outpatient,,,444.45,222.23,,,,,,Other,Not Seperately Reimbuasble,302.23,68,,241.784,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.89,20,,71.112,Percent of Total Billed Charges,20% of Total Billed Charges,88.89,20,,71.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.89,20,,71.112,Percent of Total Billed Charges,20% of Total Billed Charges,88.89,20,,71.112,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.56,80,,284.448,Percent of Total Billed Charges,80% of Total Billed Charges,377.78,85,,302.224,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,377.78,
BAG DECANTER,90062893,CDM,278,RC,,,Outpatient,,,3.11,1.56,,,,,,Other,Not Seperately Reimbuasble,2.12,68,,1.696,Percent of Total Billed Charges,68% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,0.62,20,,0.496,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.49,80,,1.992,Percent of Total Billed Charges,80% of Total Billed Charges,2.64,85,,2.112,Percent of Total Billed Charges,85% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,53.67,
IRRIGATION BULB 60ML,90062894,CDM,272,RC,,,Outpatient,,,11.07,5.54,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,20,,1.768,Percent of Total Billed Charges,20% of Total Billed Charges,2.21,20,,1.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,20,,1.768,Percent of Total Billed Charges,20% of Total Billed Charges,2.21,20,,1.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,65,,5.76,Percent of Total Billed Charges,65% of Total Billed Charges,7.2,65,,5.76,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,53.67,
SPINAL NEEDLE STERILE 22G X 5,90062895,CDM,271,RC,,,Outpatient,,,68.6,34.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.72,20,,10.976,Percent of Total Billed Charges,20% of Total Billed Charges,13.72,20,,10.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.72,20,,10.976,Percent of Total Billed Charges,20% of Total Billed Charges,13.72,20,,10.976,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.59,65,,35.672,Percent of Total Billed Charges,65% of Total Billed Charges,44.59,65,,35.672,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.72,53.67,
LMA SIZE 1,90062896,CDM,272,RC,,,Outpatient,,,65.96,32.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.87,65,,34.296,Percent of Total Billed Charges,65% of Total Billed Charges,42.87,65,,34.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,53.67,
LMA SIZE 1.5,90062897,CDM,272,RC,,,Outpatient,,,63.55,31.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.71,20,,10.168,Percent of Total Billed Charges,20% of Total Billed Charges,12.71,20,,10.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.71,20,,10.168,Percent of Total Billed Charges,20% of Total Billed Charges,12.71,20,,10.168,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.31,65,,33.048,Percent of Total Billed Charges,65% of Total Billed Charges,41.31,65,,33.048,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.71,53.67,
NASO RUSCH 18FR,90062898,CDM,270,RC,,,Outpatient,,,1.88,0.94,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,20,,0.304,Percent of Total Billed Charges,20% of Total Billed Charges,0.38,20,,0.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,20,,0.304,Percent of Total Billed Charges,20% of Total Billed Charges,0.38,20,,0.304,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,65,,0.976,Percent of Total Billed Charges,65% of Total Billed Charges,1.22,65,,0.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,53.67,
LMA SIZE 2.5,90062899,CDM,272,RC,,,Outpatient,,,65.96,32.98,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,13.19,20,,10.552,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.87,65,,34.296,Percent of Total Billed Charges,65% of Total Billed Charges,42.87,65,,34.296,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,53.67,
E T  TUBE 5 5,90062900,CDM,272,RC,,,Outpatient,,,10.4,5.20,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,20,,1.664,Percent of Total Billed Charges,20% of Total Billed Charges,2.08,20,,1.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,20,,1.664,Percent of Total Billed Charges,20% of Total Billed Charges,2.08,20,,1.664,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.76,65,,5.408,Percent of Total Billed Charges,65% of Total Billed Charges,6.76,65,,5.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,53.67,
CATH RUBBER 8FRx16,90062903,CDM,272,RC,,,Outpatient,,,10.88,5.44,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.18,20,,1.744,Percent of Total Billed Charges,20% of Total Billed Charges,2.18,20,,1.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.18,20,,1.744,Percent of Total Billed Charges,20% of Total Billed Charges,2.18,20,,1.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,7.07,65,,5.656,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.18,53.67,
ABSORBABLE HEMOSTAT 2X14,90062904,CDM,272,RC,,,Outpatient,,,187.56,93.78,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.51,20,,30.008,Percent of Total Billed Charges,20% of Total Billed Charges,37.51,20,,30.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.51,20,,30.008,Percent of Total Billed Charges,20% of Total Billed Charges,37.51,20,,30.008,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.91,65,,97.528,Percent of Total Billed Charges,65% of Total Billed Charges,121.91,65,,97.528,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.51,121.91,
SENSICLIP CLIPPER BLADE,90064832,CDM,272,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CARPEL TUNNEL KNIFE,90064833,CDM,272,RC,,,Outpatient,,,161.7,80.85,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,32.34,20,,25.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,105.11,65,,84.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.34,105.11,
SCANNER,90100001,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE K2EDTA 4ML LAV,90100514,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER BUSINESS CARD (AVERY),90110002,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHARPIE TWIN-TIP,90110190,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INTENSITY PERMANENT MARKER,90110191,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT CRP 90PK,90110192,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPERCLIP DISPENSER,90110195,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WIRELESS MOUSE,90110199,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SECURITY BAGS PATIENT MED BAG 9X12,90110200,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WATER SOLUABLE BAGS/ MELT AWAY,90110201,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OXYGEN 30 DAY REFILL,90110203,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
240/241 CANON COMBO REFILL,90110208,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
JAN-DEC 8X11 BOOK PLANNER,90110209,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERBATIM CD-RW,90110213,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SAFETY CUTTER,90110214,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OXYGEN 30 DAY DISPENSER,90110221,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SM DESK PAD 17X11,90110222,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HANGING CALENDAR,90110223,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLASSIFICATION FOLDER W/ FASTENER,90110224,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PURIFIED WATER 8OZ,90110227,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SDS BINDER,90110306,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ABG KIT,90110335,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BROCHURE & FLYER PAPER 8.5 x 11,90110336,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EMORY BOARD McKESSON 41/2IN.,90110337,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PENCIL CUP,90110341,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AVERY TENT CARDS # 5309,90110350,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RECEIPT BOOK,90110356,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FILE FOLDER EXPANDING 8.5x11,90110367,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TONER ECOTANK BLACK 502,90110378,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER SPIRAL NOTEBOOK 8x10,90110387,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAPLES B8,90110388,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PENCIL SHARPENER BOSTITCH,90110403,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PEN COUNTERFEIT TEST,90110410,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MOUNTING PUTTY (SCOTCH),90110481,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALENDAR DESK PAD,90110497,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AT-A-GLANCE WEEKLY APPT BOOK,90110498,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REFILL AT-A-GLANCE,90110499,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER BROCHURE GLOSSY TRI-FOLD,90110502,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DOTS COLOR-LT GREEN,90110503,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DOTS COLOR-YELLOW,90110504,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DOTS COLOR-RED,90110505,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AT-A-GLANCE BASE,90110510,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RHINO EAR WASH KIT,90110512,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RHINO EAR TIP REPLACE,90110513,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ULTRASOUND GEL (AQUASONIC) 8.5 OZ,90110876,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CAVI WIPES 160CT,90110877,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PROBE COVERS KIT,90110878,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE NITRILE PURPLE 12  SM,90111131,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE ENDOTRACHEAL #6.5,90120001,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DUAL NASAL CANNULA-ADULT,90120056,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FIT TEST SOLUTION SACCHARIN,90120123,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COMMODE REPLACEMENT BUCKET,90120124,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
3M SACCHARIN SENSITIVITY SOLUTION,90120125,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STEAM BIOSIGN,90120134,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EQUIPMENT COVERS/ CLEAN,90120135,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LINER-SCALE INFANT,90120136,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GENTINGE ASSURE CHEMISIX,90120172,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOOTHBRUSH,90120180,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MOUTHWASH ALC FREE 4OZ,90120192,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DEODORANT MENS,90120193,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DEODORANT WOMEN,90120194,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONDITIONER 8OZ,90120195,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHAMPOO 8OZ,90120196,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BED PAN BARIACTRIC,90120197,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BODYWASH 8OZ MENS,90120198,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHAMPOO/BODY WASH 4OZ,90120199,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MASK RESPIRATOR NON SURGICAL,90120200,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DEODORANT 1.5oz,90120201,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHARPS COLLECTOR GATOR 18GL,90120203,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHAVING CREAM,90120211,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SOAP BAR,90120212,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LOTION HAND 4oz,90120214,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REMEDY POWDER ANTIFUNGAL,90120215,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REMEDY NO-RINSE FOAM,90120216,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
B/P CUFF W/ ANEROID SPHYG. LG,90120227,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STRAWS FLEXIBLE,90120233,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EMESIS BAG DISPENSER,90120236,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHARPS COLLECTOR 8 GAL ( LAB ),90120237,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SUCTION CANISTER 1500cc,90120238,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
METRICIDE 28  1 GALLON,90120247,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GOWN/CAPE FLUID 30X21 FLUID RESISTANT,90120248,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BIOHAZARD SPILL KITS,90120249,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOWELS GREEN 18X29 OR,90120250,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COTTON BALLS UNSTERILE MD,90120253,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RAPICIDE/OPA 28 HIGH LEVEL DISINFECTANT,90120254,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SUCTION CANISTER 2000cc,90120258,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHARPS 2GAL,90120262,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHARPS 1QT PHLEBOTOMY CART,90120263,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BENZOIN AMPULE,90120271,CDM,270,RC,,,Outpatient,,,36.54,18.27,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,20,,5.848,Percent of Total Billed Charges,20% of Total Billed Charges,7.31,20,,5.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,20,,5.848,Percent of Total Billed Charges,20% of Total Billed Charges,7.31,20,,5.848,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.75,65,,19,Percent of Total Billed Charges,65% of Total Billed Charges,23.75,65,,19,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,53.67,
EXAM PAPER ROLLS,90120289,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HAIRBRUSH,90120291,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DRAPE EXAM SHEETS/100CT,90120296,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BRIEFS (UNDERPANTS) PULL-UP 2XL,90120306,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
pH PAPER ACCUTEST,90120317,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PITCHER W/ LID,90120400,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ACCUFAST TEST PACK W/ 25 CONTROLS,90120418,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INTEGRATOR STERI STEAMPLUS,90120419,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STEAM BIOLOGICAL VIALS,90120420,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ACCUFAST TEST PACK W/ 5 CONTROLS,90120421,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SKIN MARKER STERILE,90120423,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BOWIE DICK TEST PACK,90120424,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BRIEFS (UNDERPANTS) PULL-UP MED,90120425,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIAPERS ADULT LARGE,90120437,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BRIEFS (UNDERPANTS) PULL-UP LG,90120443,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIAPERS ADULT 2XL,90120447,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DIAPERS ADULT MED,90120448,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SELF-HEATING REDI+WASH,90120523,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HISTO FREEZER/WART TRTMT,90120650,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AMMONIA INHALANT,90120718,CDM,270,RC,,,Outpatient,,,5.18,2.59,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,20,,0.832,Percent of Total Billed Charges,20% of Total Billed Charges,1.04,20,,0.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,20,,0.832,Percent of Total Billed Charges,20% of Total Billed Charges,1.04,20,,0.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.37,65,,2.696,Percent of Total Billed Charges,65% of Total Billed Charges,3.37,65,,2.696,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,53.67,
HARBRUSH STANDARD,90120833,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SOCKS-NON SKID 3XL BARIATRIC,90120885,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SOCKS-NON SKID 2 XL,90120887,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SOCKS-NON SKID-LG,90120889,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SURGEON CAP BLUE,90120899,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FINGER TIPS (RUBBER),90120904,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOOTHPASTE FRESHMINT,90120906,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VINEGAR WHITE 5%,90120922,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SCRUB  MP,90132030,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SCRUB XXL,90132031,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CPR-D PADZ ADULT,90132589,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HAND SANITIZER 18OZ,90132600,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INTUBATING STYLET 10FR,90132651,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEB KITS,90132680,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPLINT CARDBOARD 12,90132696,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPLINT CARDBOARD LEG 24,90132697,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
o2 MULTISITE OXIMETER,90132698,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CHLORAPREP APPLICATOR 2%,90135939,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SKIN PREP DURAPREP 26ml,90135940,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DURAPREP LOTION/ REMOVER,90135941,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ANOSCOPE DISPOSABLE,90135944,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SANI WIPES GREY,90135946,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LUCAS 2 SUCTION CUP DISP,90135984,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPIROMETER VOLUME INCENTIVE 4000ML,90140001,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ACAPELLA VIBRATORY PEP THERAPY SYSTEM,90140002,CDM,270,RC,,,Outpatient,,,414.09,207.05,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.82,20,,66.256,Percent of Total Billed Charges,20% of Total Billed Charges,82.82,20,,66.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.82,20,,66.256,Percent of Total Billed Charges,20% of Total Billed Charges,82.82,20,,66.256,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.16,65,,215.328,Percent of Total Billed Charges,65% of Total Billed Charges,269.16,65,,215.328,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,269.16,
CANNULA CRVD-N-FLAIR W/14FT,90140003,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HUMIDIFIER BOTTLE W/ ADAPTER 500 ML,90140004,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE 2 MAC MCGRATH,90140005,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE 3 MAC MCGRATH,90140006,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE 4 MAC MCGRATH,90140007,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEBULIZER AEROSOL MASK,90140008,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FF NON VENT MASK (MD) NIV,90140009,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FF NON VENT MASK (L) NIV,90140010,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FF VENTED VENT MASK (SM) NIV,90140011,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FF VENTED VENT MASK (MD) NIV,90140012,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE 1 MAC MCGRATH,90140013,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPIRETTE MOUTHPIECE,90140014,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AIR LIFE MANUAL RESUSITATION W/O PEEP,90140015,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DETECTOR CO2 PED'S,90140016,CDM,270,RC,,,Outpatient,,,165.9,82.95,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.18,20,,26.544,Percent of Total Billed Charges,20% of Total Billed Charges,33.18,20,,26.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.18,20,,26.544,Percent of Total Billed Charges,20% of Total Billed Charges,33.18,20,,26.544,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.84,65,,86.272,Percent of Total Billed Charges,65% of Total Billed Charges,107.84,65,,86.272,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.18,107.84,
ARGYLE SUCTION CATH W/VALVE 14FR,90140017,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ARGYLE SUCTION CATH W/ VLAVE 12FR,90140018,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PRE-FILLED HUMIDIFIER 500ml,90140019,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OXYGEN CONNECTOR7MM,90140020,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VENT CIRCUIT DUAL LIMB ADULT,90140021,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PATIENT SET UP BAGS,90140022,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BALLARDS/ CATHETER 12FR,90140023,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BACTERIAL/ VIRAL FILTER,90140024,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PEEP VALVE ADULT 40  RESUSITATOR,90140025,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CANNULA EAR COVERS,90140026,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WATER TRAP DISPOSABLE,90140027,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DETECTOR CO2 ADULT,90140028,CDM,270,RC,,,Outpatient,,,129.02,64.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.8,20,,20.64,Percent of Total Billed Charges,20% of Total Billed Charges,25.8,20,,20.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.8,20,,20.64,Percent of Total Billed Charges,20% of Total Billed Charges,25.8,20,,20.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.86,65,,67.088,Percent of Total Billed Charges,65% of Total Billed Charges,83.86,65,,67.088,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.8,83.86,
CORRUGATED TUBING BLUE 6,90140029,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VENTURI MASK ADULT,90140030,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KING AIRWAY SZ5,90140031,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KING AIRWAY SZ4,90140032,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE McGRATH 1,90140033,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CIRCUITS BiPAP,90140034,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HME'S HEPA FILTER W/ PORT,90140035,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FILTERS BV STRAIGHT,90140036,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VALVED TEE ADAPTERS,90140037,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LARYNGOSCOPE FO BLADE SZ 0,90140038,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KING AIRWAY SZ0,90140039,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KING AIRWAY SZ 1,90140040,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE DISP MILLER SZ1,90140041,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASO AIRWAY 26FR,90140042,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
E T  TUBE 2 5,90140043,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
E T  TUBE 4 0,90140044,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
E T  TUBE UNCUFFED 4 0,90140045,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
McGRATH BATTERY 3.6V,90140046,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RESTING TABS ECG,90140047,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CIRCUIT DELETED,90140048,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INSTRUMENT TRAY SS 8X5X2,90140049,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEBULIZER EMPTY 350ml,90140050,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASAL VENTED MASK (NIV) MD,90140051,CDM,270,RC,,,Outpatient,,,218.5,109.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.7,20,,34.96,Percent of Total Billed Charges,20% of Total Billed Charges,43.7,20,,34.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.7,20,,34.96,Percent of Total Billed Charges,20% of Total Billed Charges,43.7,20,,34.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.03,65,,113.624,Percent of Total Billed Charges,65% of Total Billed Charges,142.03,65,,113.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.7,142.03,
UNIVERSAL CUFF ADAPTER,90140052,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ELI-250 PAPER MORTARA,90140053,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASAL VENTED MASK (NIV) LG,90140054,CDM,270,RC,,,Outpatient,,,218.5,109.25,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.7,20,,34.96,Percent of Total Billed Charges,20% of Total Billed Charges,43.7,20,,34.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.7,20,,34.96,Percent of Total Billed Charges,20% of Total Billed Charges,43.7,20,,34.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.03,65,,113.624,Percent of Total Billed Charges,65% of Total Billed Charges,142.03,65,,113.624,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.7,142.03,
FF VENTED VENT MASK (LG) NIV,90140055,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NON-REBREATHER PEDIACTRIC,90140059,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STRAIGHT CONNECTOR U/ADAPT-IT,90140061,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
3-IN-1 MASK ADULT AIRLIFE,90140062,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
(BOUGIE) INTRODUCER 15FR,90140065,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
5.5 ENDOTRACH W/ STYLETTE CUFFED,90140066,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KING AIRWAY SZ 3,90140067,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CHRISTMAS TREE ADAPTER,90140068,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE DISP MILLER SZ2,90140069,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE DISP MAC #2,90140070,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
4.5 ENDOTRACH W/STYLETTE UNCUFFED,90140071,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
5.5 ENDOTRACH W/ STYLETTE UNCUFFED,90140072,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
14FR NPA PEDS,90140073,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MDI ADAPTOR INLINE 22MM,90140074,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ABG KIT 3ML LITH HEPARIN,90140075,CDM,270,RC,,,Outpatient,,,118.03,59.02,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.61,20,,18.888,Percent of Total Billed Charges,20% of Total Billed Charges,23.61,20,,18.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.61,20,,18.888,Percent of Total Billed Charges,20% of Total Billed Charges,23.61,20,,18.888,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.72,65,,61.376,Percent of Total Billed Charges,65% of Total Billed Charges,76.72,65,,61.376,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.61,76.72,
HI-FLOW DISP PATIENT CIRCUIT,90140076,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FEP BiPAP CIRCUIT,90140077,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OPTI B-CASSETTES,90140078,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GAS BOTTLE OPTI,90140079,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
E-CL TYPE CASSETTES,90140080,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CVC123 CALIBRATION VERIF CONTROLS,90140081,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
3.0 ENDOTRACHEAL UNCUFFED,90140082,CDM,270,RC,,,Outpatient,,,17.35,8.68,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,3.47,20,,2.776,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,65,,9.024,Percent of Total Billed Charges,65% of Total Billed Charges,11.28,65,,9.024,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,53.67,
4.0 ENDOTRACHEAL UNCUFFED,90140083,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OPTI CHECK +,90140084,CDM,270,RC,,,Outpatient,,,223.54,111.77,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.71,20,,35.768,Percent of Total Billed Charges,20% of Total Billed Charges,44.71,20,,35.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.71,20,,35.768,Percent of Total Billed Charges,20% of Total Billed Charges,44.71,20,,35.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.3,65,,116.24,Percent of Total Billed Charges,65% of Total Billed Charges,145.3,65,,116.24,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.71,145.3,
"KIT, PERISTALTIC PUMP",90140085,CDM,270,RC,,,Outpatient,,,280.44,140.22,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.09,20,,44.872,Percent of Total Billed Charges,20% of Total Billed Charges,56.09,20,,44.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.09,20,,44.872,Percent of Total Billed Charges,20% of Total Billed Charges,56.09,20,,44.872,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.29,65,,145.832,Percent of Total Billed Charges,65% of Total Billed Charges,182.29,65,,145.832,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,182.29,
OPTI PRINTER PAPER,90140086,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OPTI TRI-CHECK QC,90140087,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HEPARINIZED CAPILLARY TUBE,90140088,CDM,270,RC,,,Outpatient,,,117.71,58.86,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.54,20,,18.832,Percent of Total Billed Charges,20% of Total Billed Charges,23.54,20,,18.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.54,20,,18.832,Percent of Total Billed Charges,20% of Total Billed Charges,23.54,20,,18.832,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.51,65,,61.208,Percent of Total Billed Charges,65% of Total Billed Charges,76.51,65,,61.208,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.54,76.51,
OPTI tHb CASSETTE,90140089,CDM,270,RC,,,Outpatient,,,88.41,44.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.68,20,,14.144,Percent of Total Billed Charges,20% of Total Billed Charges,17.68,20,,14.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.68,20,,14.144,Percent of Total Billed Charges,20% of Total Billed Charges,17.68,20,,14.144,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.47,65,,45.976,Percent of Total Billed Charges,65% of Total Billed Charges,57.47,65,,45.976,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.68,57.47,
VENT CIRCUIT DELETED,90140090,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MULTI-LEVEL SRC,90140091,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MINI-HEART NEB,90140092,CDM,270,RC,,,Outpatient,,,161.01,80.51,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,20,,25.76,Percent of Total Billed Charges,20% of Total Billed Charges,32.2,20,,25.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,20,,25.76,Percent of Total Billed Charges,20% of Total Billed Charges,32.2,20,,25.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.66,65,,83.728,Percent of Total Billed Charges,65% of Total Billed Charges,104.66,65,,83.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,104.66,
BLADE DISP MAC #3,90140093,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
3.0 ENDOTRACHEAL UNCUFFED,90140094,CDM,270,RC,,,Outpatient,,,29.64,14.82,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.93,20,,4.744,Percent of Total Billed Charges,20% of Total Billed Charges,5.93,20,,4.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.93,20,,4.744,Percent of Total Billed Charges,20% of Total Billed Charges,5.93,20,,4.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.27,65,,15.416,Percent of Total Billed Charges,65% of Total Billed Charges,19.27,65,,15.416,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.93,53.67,
mBRACE THOMAS TUBE HOLDER,90140095,CDM,270,RC,,,Outpatient,,,12.59,6.30,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,20,,2.016,Percent of Total Billed Charges,20% of Total Billed Charges,2.52,20,,2.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,20,,2.016,Percent of Total Billed Charges,20% of Total Billed Charges,2.52,20,,2.016,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.18,65,,6.544,Percent of Total Billed Charges,65% of Total Billed Charges,8.18,65,,6.544,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,53.67,
ADAPTER SAFETY HOLDER,90150001,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
APPLICATOR COTTON TIP 6IN N/S,90150002,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
APPLICATOR STICK WOOD 6,90150003,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BAG BIO SPCMN ZIP POCKET 6x9,90150004,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BADANGE COBAN 1x5 MULTI,90150005,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BANDAGE COBAN 2x5 MULTI,90150006,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT 1 VITROS (4CAL/BOX),90150007,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT 11 VITROS CAL 6 EVENT BOX,90150008,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT2 VITROS 250/950 (4CAL/BOX,90150009,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT 29 VITROS (2/BX),90150010,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT 3 VITROS (4CAL/BX),90150011,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT 4 VITROS (4CAL/BOX,90150012,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT 8 VITROS 250 (2CAL/BX),90150013,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT 9 VITROS 250 (2ST/BX0,90150014,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT DIRECT HDL 25,90150015,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR B12,90150016,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR CK-MB 2,90150017,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR FOLATE,90150018,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR NT-PROBNP 2,90150019,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR PSA,90150020,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR TROPONIN,90150021,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR TSH,90150022,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR VITAMIN D,90150023,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CAPS F/CUPS (SAMPLE CUP),90150024,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CARTRIDGE VAPOR ADSORPTION,90150025,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CHART CIRCULAR 7-DAY 4.5IN,90150026,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLEANER CA CLEAN I,90150027,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLEANER CA CLEAN II,90150028,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT LAB HIP MED,90150029,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT LAB HIP XSM,90150030,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT LAB 2XL,90150031,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT LAB HIP SM,90150032,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLLECTION SET SAFETY 25GX3/4 W 12  TUBE,90150034,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL AFINION HBA1C,90150035,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL INFLUENZA SWAB A + B,90150036,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COVER GLASS #1 PREM 22X22 MM,90150037,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CUP MICRO SAMPLE,90150038,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CUP SAMPLE 1ML 13MM,90150039,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CUP SAMPLE 2ML,90150040,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CUVETTE FS F/VITROS,90150041,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DESSICANT PACK VITROS 250/350,90150042,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DEVICE BLOOD TRANSFER VACUETTE STERILE,90150043,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DILUENT PACK 1 FS,90150044,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DILUENT PACK 2 FS BSA/SALINE,90150045,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DILUENT PACK 3 FS,90150046,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DILUENT HIGH SAMPLE B,90150047,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DILUENT RECONSTITUTION,90150048,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DILUENT SAMPLE A F/ VITROS ECI,90150049,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLEACH GERMICIDE 121OZ,90150050,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DISPENSER BLOOD SMEARSAFE,90150051,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR FERRITIN,90150052,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FLUID REFERENCE FS950,90150053,CDM,270,RC,,,Outpatient,,,383.11,191.56,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.62,20,,61.296,Percent of Total Billed Charges,20% of Total Billed Charges,76.62,20,,61.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.62,20,,61.296,Percent of Total Billed Charges,20% of Total Billed Charges,76.62,20,,61.296,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.02,65,,199.216,Percent of Total Billed Charges,65% of Total Billed Charges,249.02,65,,199.216,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,249.02,
HOLDER SAFETY W/FML ADPTR,90150054,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HOLDER TUBE BC,90150055,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HUMIDIFICATION PACK,90150056,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
IMMUNO-WASH FLUID,90150057,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LINER A WASTE VITROS 5600,90150058,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LINER B WASTE VITROS 5600,90150059,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LINER C SLIDE BOX FS DISP,90150060,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MAILER TWO SLIDE 3787,90150061,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MAINTENANCE PACK VITROS EciQ,90150062,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
METHANOL ACS GRADE 99%,90150063,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
METHANOL 100%,90150064,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MICRO SENSOR CK FLS,90150065,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MICROTIPS FS F/VITROS,90150066,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER TEMP CHART 6IN,90150067,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER PERFORMANCE LV1,90150068,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER PERFORMANCE LV2,90150070,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPETTE TIPS MLA,90150071,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPETTE TRANSFER 5ML,90150072,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPETTE TRANSFER 7ML,90150073,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER CK-MB VITROS ECI,90150074,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT ACETAMINOPHEN VIT250,90150075,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT ALCOHOL-18,90150076,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT ALKP/ TBIL DUAL SLIDE,90150077,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT B12 FOLATE,90150078,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT CELLPACK 20L,90150079,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT CK-MB (CKMB) 2,90150080,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT UREA/ CREAT DUAL SLIDE,90150081,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT DIRECT TOTAL IRON BINDING,90150082,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT FERRITIN,90150083,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT FOLATE,90150084,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT FREE T4,90150085,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT LIPASE,90150086,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT NT-PROBNP 2,90150087,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT PSA,90150088,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT SALICYLATE,90150089,CDM,270,RC,,,Outpatient,,,288.47,144.24,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.69,20,,46.152,Percent of Total Billed Charges,20% of Total Billed Charges,57.69,20,,46.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.69,20,,46.152,Percent of Total Billed Charges,20% of Total Billed Charges,57.69,20,,46.152,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.51,65,,150.008,Percent of Total Billed Charges,65% of Total Billed Charges,187.51,65,,150.008,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,187.51,
REAGENT SIGNAL,90150090,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT SODIUM NA+,90150091,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT STROMAT,90150092,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT STROMATOLYSER 4DL 5L,90150093,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT STROMATOLYSER 4DS 42ML,90150094,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT SULFOLYSER 3X500ML,90150095,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT TROPONIN,90150096,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT TSH,90150097,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT UNIVERSAL WASH,90150098,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT VANCOMYCIN,90150099,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT VITAMIN B 12 FOLATE DENAT F/VITR,90150100,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT VITAMIN D 100 TESTS,90150101,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT ALBUMIN/ TOTAL PROTEIN DUAL SLID,90150102,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT ALTV/ AST DUAL SLIDE,90150103,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT AMYLASE,90150104,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT AST/SGOT-60,90150105,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT BUBC,90150106,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT BUN,90150107,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT CALC/ GLU DUAL SLIDE,90150108,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT CHLORIDE,90150109,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT CHOL/ TRIG DUAL SLIDE,90150110,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT CK,90150111,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT DIGOXIN,90150112,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT ENZYMATIC,90150113,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT GLUCOSE,90150114,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT IRON,90150115,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT MAGNESIUM,90150116,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT PHOSPHORUS,90150117,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT POTASSIUM,90150118,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT TBIL,90150119,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT TOTAL PROT,90150120,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT TRIGL,90150121,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT URIC ACID,90150122,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SEGMENT DEVICE BLOOD SAMP F/BLDBG TUBE H,90150123,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDE ACETAMINOPHEN,90150124,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDE DIRECT HDL,90150125,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDE KOVE FAST READ 102,90150126,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDE LACTATE-60,90150127,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDE MICRO FROSTED ETCHED 25X75MM,90150128,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SOLUTION BSA 7% 12X5 ML,90150129,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAIN HEMA-DIFF II XANATHENE GL,90150130,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAIN HEMA-DIFF II THIAZINE DYE,90150131,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STAIN POTASSIUM HYDROXIDE KOH 10% 2OZ,90150132,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SWABSTICK PVP (POVIDONE-IODINE),90150133,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TABLET INSTANT BLUING F/DRUG SCREEN,90150134,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"LIQUICHECK, ELEV CPR 1ML",90150136,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT C DIFF COMPLETE,90150137,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT HBA1C HEMOGLOBIN AFINION GLYCTD,90150138,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TIP VERSA F/VITROS CHEM SYST,90150139,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER TROPONIN ES,90150140,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE CENTRIFUGE CLR 15ML,90150141,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE CULTURE DISP 12X75,90150142,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE REACTION F/SYSMEX CA SERIES,90150143,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/HEMOGARD PLUS 2ML (LAVENDAR),90150144,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/HEMOGARD PLUS 3ML (GREEN),90150145,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE CITRATE 1.8 ML (BLUE/WHITE,90150146,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE PULL CAP 2.5ML (GREEN/BLAC,90150147,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE PULL CAP 3ML (GREEN/BLACK),90150148,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE PULL CAP 5ML (RED/YELLOW),90150149,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
URINE TEST STRIP MULTISTIX 10 SG,90150150,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE EDTA 2ML LAV,90150151,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER B12 VITROS ECI,90150152,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER FERRITIN ECI VITROS,90150153,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER FOLATE ECI VITROS,90150154,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER LIQUID PERFORMANCE II,90150155,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER LIQUID PERFORMANCE I,90150156,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER PERFORMANCE-I dTIBC,90150157,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER PERFORMANCE-II dTIBC,90150158,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER PSA VITROS ECI,90150159,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER FREE T4,90150160,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER RANGE FSH MICROWELL,90150161,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER RANGE NT-PROBNP MIRCROWELL,90150162,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER TSH ECI VITROS,90150163,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER TDM PERFM,90150164,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER TDM PERFORMANCE I,90150165,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER TDM PERFORMANCE III,90150166,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR FREE T4 ECI VITROS,90150167,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE LITH HEP (GRN/YLW W/GEL),90150168,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FILTER AIR CARD RACK FS,90150169,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/ HEMOGARD PLUS LT GRY 4ML,90150170,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/ HEMOGARD + CITR LT BLU 2.7ML,90150171,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEEDLE HYPO EDGE SAFETY 18Gx1,90150172,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT AHG IGG GRN 1x10ML,90150173,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL TRAIGE TOTAL 5 LEVEL 2,90150174,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL TRAIGE TOTAL 5 LVL 1,90150175,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT WAIVED BINAX RSV22,90150176,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLLECTION SET SAFETY 23GX3/4,90150177,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLLECTION SET SAFETY LUER 21Gx3/4,90150179,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPETTE TRANSFER 3ML,90150180,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THERMOMETER IR GUN INFARED,90150181,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BP MONITOR DESK MODEL,90150182,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WEDGE PHLEBOTOMY ARM & WRIST,90150183,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CLEANER LENS GLASS 2oz,90150184,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER LENS MGM63,90150185,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER SYSMEX THERMAL,90150186,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BAG SPECIMAN RECL LAB 6X9,90150187,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER CRP #2,90150188,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT MONO 25/KT,90150189,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER CRP #1,90150190,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT VITROS LDH 50/PK,90150191,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT STREP A DIPSTICK,90150192,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CALIBRATOR KIT #7 VITROS 250,90150193,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"CONTROL, IMMUNO LEVEL 1",90150194,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TABLET KETONE AIMTAB,90150195,CDM,270,RC,,,Outpatient,,,48.31,24.16,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,20,,7.728,Percent of Total Billed Charges,20% of Total Billed Charges,9.66,20,,7.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,20,,7.728,Percent of Total Billed Charges,20% of Total Billed Charges,9.66,20,,7.728,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.4,65,,25.12,Percent of Total Billed Charges,65% of Total Billed Charges,31.4,65,,25.12,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,53.67,
TEST KIT HEMOCCULT SNG 2HOLE,90150196,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT BINAXNOW INFLUENZA A&B,90150197,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT ALTV/5,90150198,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
H PYLORI RAPID TEST,90150199,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WIPE ACCUWIPE 4.5 x 8,90150200,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BIO-WIPE 3X3,90150201,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFIER EPOC EUROTROL GAS 5LVL,90150202,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL EPOC GAS-ISE/BUN 3LVL,90150203,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL EPOC EUROTROL GAS-ISE/BUN 1LVL,90150204,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CARD TEST EPOC F/BLOOD GAS,90150205,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL EPOC GAS-ISE,90150206,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL EPOC GAS-ISE LVL2,90150207,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT TROPONIN W/CKMB,90150208,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRIAGE TOX SCREEN TEST,90150209,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRIAGE TOTAL 5 VERIFICATION,90150210,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PANEL EVAL DRUG SCREEN TOX 3.0,90150211,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRIAGE BNP TEST,90150212,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRIAGE DRUG SCREEN LV1,90150213,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRIAGE DRUG SCREEN LV2,90150214,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DEVELOPER GASTROCULT 15ML,90150215,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDES GASTROCULT 40/BOX,90150216,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DRUG CONTROL KIT ISCREEN + -,90150217,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDE PLAIN 25X75X1,90150218,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CARD PACK CAL CHECK READER,90150219,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAGULATION CA CAL S,90150220,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SALINE BLOOD BANK,90150221,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SIGNIFY TOX ER DRUG SCREEN,90150222,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPETTE D-TIPPER 1000UL,90150223,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THERMOMETER INCUBATOR 0-100C,90150224,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL SWAB RSV NOW,90150225,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRIAGE D-DIMER TEST,90150226,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE PULL CAP 8.5 ML (RED/GREY),90150227,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VACUTAINER RED 16x100MM 10ML,90150228,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
URINE MICRO QC,90150229,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CARDIAC PANEL TRIAGE,90150230,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRIAGE TOX LEVEL 1,90150231,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRAIGE TOX LEVEL 2,90150232,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CARDIAC MARKER CONTROL #1,90150233,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CARDIAC MARKER CONTROL #3,90150234,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DEIONIZED WATER REAGENT GRADE,90150235,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BD MIRCOTAINER SST,90150236,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT LAB XL / PINK,90150237,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT LAB MED / WHITE,90150238,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LABEL THERMAL ID NOW PRINTER,90150239,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE CAPILLARY EPOC 1129861,90150240,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRANSFER NEEDLE STEEL EPOC,90150241,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT COVID-19 ID NOW,90150242,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL KIT COIVD-19 ID NOW,90150243,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE CAPILLARY MINI LAV .5ML,90150244,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLOOD STR RED 3ML,90150245,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE LL 10CC,90150246,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SYRINGE LL  5CC,90150247,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE MICROTAINER W/O ADDITIVE,90150248,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT H PYLORI,90150249,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPECIMAN CUP,90150250,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EPOC PAPER ROLLS,90150251,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASOPHARYNGEAL COLLLECTION SWAB 6in,90150252,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT LAB HIP 5XL,90150253,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DISPENSER DIFF-SAFE,90150254,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TIP PIPETTE FIN62,90150255,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SWABSTICK CALCIUM ALGINATE,90150256,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE PULL CAP 7ML (RED/YELLOW),90150257,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST PREG HGC,90150258,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT B12,90150259,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLD LIHEP 2ML GRN,90150260,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PANEL TRIAGE CARDIAC,90150261,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/HEMOGARD (BLUE) 2.7ML,90150262,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE GRN 4ML,90150263,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC GLUCOSE 2ML GRY/WHT,90150264,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WARMER HEEL INF 3.75x5.5,90150265,CDM,270,RC,,,Outpatient,,,20.81,10.41,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.16,20,,3.328,Percent of Total Billed Charges,20% of Total Billed Charges,4.16,20,,3.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.16,20,,3.328,Percent of Total Billed Charges,20% of Total Billed Charges,4.16,20,,3.328,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.53,65,,10.824,Percent of Total Billed Charges,65% of Total Billed Charges,13.53,65,,10.824,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.16,53.67,
TEST TUBE 16X100,90150266,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL TIP DROPPER,90150267,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SAFE-T HOLDER MALE LL,90150268,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/HEMOGARD+ CITR 2.7,90150269,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE HEMOGARD+ SST GOLD 5ML,90150270,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
RANGE VERIFIER NT-PROBNP 2,90150271,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE CITRATE 1.8ML,90150272,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE URINE AMES TYPE,90150273,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE 4.5 LT BLU,90150274,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TIP PIPETTE PINK 0.2,90150275,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BULB CENTRIFUGE 5W,90150276,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
APPLICATOR POLY TIP PLAS STERILE,90150277,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/HEMO 3.5 ML GOLD,90150278,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/HEMOGARD 4.5 GRN,90150279,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EXAM GLOVE LG CONFIDERM,90150280,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/HEMO+EDTA LAV 4ML,90150281,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT LAB LG,90150282,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CAP FLANGE PLUG 12MM,90150283,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAD ALCOHOL 200BX,90150284,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDE LDHI TRACEABLE,90150285,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLD CLOT/SEP RED/GRY 7.5 ML,90150286,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SLIDE URINE FAST READ,90150287,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE K2EDTA 3ML,90150288,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VACUETTE RED/BLK 6ML,90150289,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SPOUT KIT CUBATAINER #1,90150290,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE K2EDTA 6ML,90150291,CDM,270,RC,,,Outpatient,,,4.63,2.32,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,20,,0.744,Percent of Total Billed Charges,20% of Total Billed Charges,0.93,20,,0.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,20,,0.744,Percent of Total Billed Charges,20% of Total Billed Charges,0.93,20,,0.744,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.01,65,,2.408,Percent of Total Billed Charges,65% of Total Billed Charges,3.01,65,,2.408,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,53.67,
TUBE RED 4ML,90150292,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROL H PYLORI,90150293,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE CAPILLARY CLOT/SEP 400/600,90150294,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE CAPILLARY K2EDTA MICROTAINER,90150295,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE CAPILLARY LIHEP/SEP 400/600UL,90150296,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE RED 10ML GLS,90150297,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLUE 2ML SODCIT,90150298,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE CLOT/SEP GLD 5ML,90150299,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLLECTION SET 21X.75,90150300,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLLECTION SET 25G X 3/4,90150301,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLD COL LIHEP 2ML VACUETTE,90150302,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLD COL NA2EDTA 2ML,90150303,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/SODCIT LTBLU/WHT 2ML,90150304,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CAL CHLORIDE,90150305,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"CONTROL, IMMUNOLOGY LEVEL 1",90150306,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"CONTROL, ETH/ AMMONIA LEVEL 2",90150307,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"CONTROL, ETH/ AMMONIA LEVEL 1",90150308,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MOIST MARK SLIDE PEN,90150309,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLD CLOT RED 6ML,90150310,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST KIT COVID AG,90150311,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"LIQUICHECK, IMMUNOASSAY LEVEL 1",90150312,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"LIQUICHECK, IMMUNOASSAY +CONTROL LVL2",90150313,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"LIQUICHECK, PED'S LEVEL1",90150314,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STREP TEST A2,90150315,CDM,270,RC,,,Outpatient,,,123.5,61.75,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.7,20,,19.76,Percent of Total Billed Charges,20% of Total Billed Charges,24.7,20,,19.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.7,20,,19.76,Percent of Total Billed Charges,20% of Total Billed Charges,24.7,20,,19.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.28,65,,64.224,Percent of Total Billed Charges,65% of Total Billed Charges,80.28,65,,64.224,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.7,80.28,
REAGENT AMMONIA,90150316,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"CALIBRATOR, B-HCG 2",90150317,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"REAGENT, B-HCG 2",90150318,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CULTURE SWAB TRANSPORT & COLLECTION,90150319,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CANNULA NASAL PEDIACTRIC,90150320,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE VAC/ HEMOGARD PLUS LT GRY 2ML,90150321,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REAGENT ALBUMIN,90150322,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CMP PICCOLO PANEL TEST,90150323,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"TIP, PIPETTE 0.5-200UL",90150324,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LIQUICHECK PED'S LVL2,90150325,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLOOD DRAW KIT,90150503,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLD RE/GRY 3ML VACUTAINER,90150504,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TEST OCCULT SGL SLIDE,90150505,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE BLD CLOT RE/WHT 2ML,90150506,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLLECTION SET 23GX3/4,90150507,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
WIPE KIMWIPE 12X12,90150508,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"TIP, PIPETTE 100-1000UL",90150509,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PIPETTOR DIAMOND 100-1000UL,90150510,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"TIP, PIPETTE 1-5",90150511,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"PIPETTE , 1-5ML",90150512,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CITROL 1/20X1,90150513,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CITROL 3/20X1,90150514,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INNOVIN 10X4,90150515,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ACTIN FSL 10X2,90150516,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"BAG, RECLOSABLE 12X15",90150517,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"KIT, PICCOLO VERIF 3L x3VIAL",90150518,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MAXINEB DUO W/FILTER,90160084,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH SELF SEAL 5.5X10,90162006,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH 7.5X13,90162007,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH 2.25 X 4,90162008,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH 3.5 X 5,90162009,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH 3.5 X 5.25,90162010,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH 2.25 X 4,90162011,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE NITRILE PURPLE 12  SM,90162131,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE NITRILE PURPLE 12  MED,90162132,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GL0VE NITRILE PURPLE 12  LRG,90162133,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
THERA-TEARS 16.8 GEL DROPS,90162135,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ELECTROSURGICAL PLATE W/ CORD,90162136,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION CONTAINER FILTERS,90162137,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CONTROLS AQ EUROTROL GLUC,90162138,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE NITRILE PURPLE 12  XL,90162139,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 2 TONED 18X18,90162239,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 2 TONED 24X24,90162240,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 2 TONED 36X36,90162241,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 18X18,90162242,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 12X12,90162243,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TRAY LINER 48X62,90162244,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SUITCASE TAGS,90162245,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ANTI-FOG SOLUTION MASK,90162246,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COVERALL/ BUNNY SUIT,90162247,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DRAIN PENROSE STERILE,90162248,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MAT SILICONE 18.5 X 9.5,90162252,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STRINGERS WEINSTEIN 2.5 X 14,90162253,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SURGICAL DRAPE 1/2,90162266,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILE BASIC LAPAROTOMY TRAY,90162267,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SCALPEL # 11,90162271,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AVAGARD HAND ANTISEPTIC,90162272,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TOWELS DISPOSABLE BLUE/OR,90162273,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SURGICAL SCRUB BRUSH/ CHLOROXYLENOL,90162274,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE CHEMO/FENTANYL LG,90162275,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PROTECTORS FOAM SHEET SLOTS,90162276,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KOALA SPONGE,90162277,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENDOZIME SPONGE,90162278,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INDICATOR CARDS,90162279,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TAMPERPROOF LOCK/ STEAM,90162280,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BRUSH NYLON TOOTHBRUSH STYLE 7,90162281,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BRUSH SS BRISTLE TOOTHBRUSH STYLE DBL EN,90162282,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 45x45,90162283,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 36X36,90162284,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 24X24,90162285,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"TOWEL, SEQUENCE PT ROOM",90162286,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"TOWEL, SEQUENCE RR ORANGE",90162287,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
"TOWEL, SEQUENCE DISCHARGE PURPLE",90162288,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BASIN BASIC SINGLE,90162289,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LITHOTOMY PACK IV,90162290,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DISPOSABLE LEG WELL HOLDER,90162291,CDM,270,RC,,,Outpatient,,,454.78,227.39,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.96,20,,72.768,Percent of Total Billed Charges,20% of Total Billed Charges,90.96,20,,72.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.96,20,,72.768,Percent of Total Billed Charges,20% of Total Billed Charges,90.96,20,,72.768,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.61,65,,236.488,Percent of Total Billed Charges,65% of Total Billed Charges,295.61,65,,236.488,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,295.61,
O R TOWEL BLUE STERILE DISP,90162292,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
POSITIONER BEAN BAG 40X30,90162293,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CORD REUSABLE BIPOLAR CORD,90162294,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SCALPEL #10 BLADE,90162295,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SCALPEL #15 BLADE,90162296,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
CELERITY 20 STEAM CONTROLS,90162297,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERDOC BIOLOGICAL INDICATOR,90162298,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFY STEAM INTEGRATING INDICATOR,90162299,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENZY CLEAN CLEANER,90162403,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER SELF POUCH 3.5 X 9,90162603,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EXAM GLOVE MD CONFIDERM,90162737,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EXAM GLOVE SM CONFIDERM,90162738,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERILIZATION WRAP 2 TONED 45X45,90162739,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COAT OR HIP 5XL,90162740,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PROLYSTICA ENZY PRESOAK & CLEANER,90162741,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PROLYSTICA NEUTRAL DETERGENT,90162742,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HINGE-FREE WR 2.64 GAL,90162743,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFY ALL CLEAN INDICATOR,90162744,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERIFY ALL CLEAN HOLDER,90162745,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VERDOC ALL CLEAN INDICATOR LOG,90162746,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
POSITIONER GEL HORSEHOE 8X3X2,90162752,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLADE DISPOSABLE D MILLER SZ3,90162753,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FIBER OPTIC MAC BLADE #1,90162754,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FIBER OPTIC MAC BLADE #3,90162755,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
FIBER OPTIC MAC BLADE #4,90162756,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
HANDLE FIBER OPTIC LARYNGOSCOPE,90162757,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASO AIRWAY 20FR,90162760,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASO AIRWAY 28FR,90162761,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASO AIRWAY 30FR,90162762,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASO AIRWAY 32FR,90162763,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASO AIRWAY 34FR,90162764,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASO AIRWAY 36FR,90162765,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASO AIRWAY 24FR,90162766,CDM,270,RC,,,Outpatient,,,34.42,17.21,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.88,20,,5.504,Percent of Total Billed Charges,20% of Total Billed Charges,6.88,20,,5.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.88,20,,5.504,Percent of Total Billed Charges,20% of Total Billed Charges,6.88,20,,5.504,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.37,65,,17.896,Percent of Total Billed Charges,65% of Total Billed Charges,22.37,65,,17.896,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.88,53.67,
AIRWAY 60MM,90162767,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AIRWAY 80MM,90162768,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AIRWAY 90MM,90162769,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE GUIDE TRACH INTUBATION,90162770,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ANESTHESIA CIRCUIT TREE,90162771,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INSUFFLATION TUBING STERILE,90162773,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBING SUCTION STERILE 20,90162777,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBING 3/16 x 1.5,90162778,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PRE-KLENZ INSTRUMENT PRE-SOAK,90162779,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ANESTHESIA MASK NEO SIZE 0,90162780,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ABSORBER Co2 (SOMA),90162794,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
OPA 28 TEST STRIPS,90162795,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MINI-SPIKE DISPENSING PIN,90162798,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENDOSCOPY KIT,90162809,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GOWN PROCEDURE,90162812,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INTERCEPT DETERGENT,90162814,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH STERILIZATION 8X16,90162815,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH STERILIZATION 12X15,90162816,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH STERILIZATION 5X15,90162817,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PAPER POUCH STERILIZATION 3.5 X 22,90162818,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SCOPESAVER (BITE BLOCK),90162819,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SURGIFLO HEMO KIT,90162856,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ANTIFOG SOLUTION W/ SPONGE,90162857,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
N/S TONGUE DEPRESSOR 6,90162860,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LAP SURGICAL PACK,90162864,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SURGICAL MAYO STAND COVER,90162865,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
LITHOTOMY FLUID POUCH,90162866,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BOVIE PAD (NEONATAL),90162868,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DRAPE L 70X85,90162873,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GLOVE NITRILE PURPLE 12  L,90162875,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
VENI-CATH DRESSING,90162879,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLUNT TIP NEEDLE 18X1,90162880,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENDO TATTOO MARKER,90162881,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BREATHING BAGS KING 2L,90162884,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
MASK ANES CHILD BUBBLE GUM 3,90162885,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ANESTHESIA CIRCUIT PED'S,90162886,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ARMBOARD POSITIONER 2X8X20,90162893,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERRAD VELOCITY INDICATOR,90162894,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STERRAD NX SYSTEM CASSETTE 5 CYCLE,90162895,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
TUBE K2EDTA 3ML LAV,90162896,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLLECTION SET 25GX3/4,90162897,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
COLLECTION TUBE HOLDER w/,90162898,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DRAPE SURGICAL 20X30,90162901,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BLOCK TRAY UNIV W/O RX,90162902,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EPIDURAL NEEDLE 20Gx4.5,90162903,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EPIDURAL NEEDLE 20Gx6,90162904,CDM,270,RC,,,Outpatient,,,299.75,149.88,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,59.95,20,,47.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.84,65,,155.872,Percent of Total Billed Charges,65% of Total Billed Charges,194.84,65,,155.872,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,194.84,
DISP BPSY FRCP AGTR LC W/NDL 2.8MM 230CM,90162905,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DISP BIO FORCEP GATOR JAW W/NEDL 3.2MM C,90162906,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SD-210U-25 DISP SNARE,90162907,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
AUX CHANNEL WATER JET ADAPTOR STERILE,90162908,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
QUICKCLIPPRO SINGLE USE 230CM 2.8MM,90162909,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
DISP COMBO CLEANING BRUSH 2.0-4.2MM,90162910,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
60FR MOUTHPIECE,90162911,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NEUTRAL ELECTRODE ADULT W/ CABLE,90162912,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INTUBATING STYLETTE FLEXI-SLIP 14FR,90162913,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
BOVIE PAD W/O CABLE,90162914,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
EZ-DILATE BLN DIL 16-17-18 190,90162915,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REVOWAVE GUIDEWIRE 0.035 260 TIP 25,90162916,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
PROTECH DISTAL TIP PROTECTOR,90162917,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INFLATION DEVICE FOR EZDILATE,90162918,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
KIT UP ECO SY GP EB LB,90162919,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ENDOCUFF VISIN SM PURPLE I D,90162920,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
STOPCOCK: 4 WAY W/33  TUBING,90162921,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
McGRATH X3 BLADE,90162922,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
GETINGE PAPER ROLLS,90162923,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
INTUBATING STYLETTE FLEXI-SLIP 12FR,90162924,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
SHEET STRETCHR POLY 40X90,90164830,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
NASAL VENTED MASK (NIV) SM,90170055,CDM,270,RC,,,Outpatient,,,222.55,111.28,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.51,20,,35.608,Percent of Total Billed Charges,20% of Total Billed Charges,44.51,20,,35.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.51,20,,35.608,Percent of Total Billed Charges,20% of Total Billed Charges,44.51,20,,35.608,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.66,65,,115.728,Percent of Total Billed Charges,65% of Total Billed Charges,144.66,65,,115.728,Percent of Total Billed Charges,65% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.51,144.66,
ADMISSION DIVIDER 1ST CUT,90180639,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ADMISSION DIVIDER 2ND CUT,90180669,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
ADMISSION DIVIDER 3RD CUT,90180670,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,
REALSPACE HIGH BACK CHAIR/BLACK,90180671,CDM,270,RC,,,Outpatient,,,,,,,,,,Other,Not Seperately Reimbuasble,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Case Rate,Pays Based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,53.67,